GYNECOLOGY

FAMILY PLANNING (HORMONAL)

DR. AVSJ
OLFU • FUMC  COLLEGE OF MEDICINE
Reference: COMPREHENSIVE GYNECOLOGY 7th Ed. Lobo | Gershenson | Lentz Valea

OBJECTIVES:  hybrid progestin (from estrane group

• OCP
• LONG-ACTING HORMONAL CONCENTRATION  Closer to the pregnane group; does
• INTRAUTERINE DEVICE / SYSTEM not exert the androgenic effect of
• STERILIZATION Testosteron

INTRODUCTION • Inhibition of midcycle gonadotropin surge

CASE: and prevention of ovulation (more
A 32 year old G3P3 breastfeeding mother, who delivered 6 Mechanism of consistent for combined than minipill)
weeks ago, comes to ask for a method of delivered 6 weeks ago, comes Action • Progestin action- thick, viscid, scanty
to ask for a method of family planning. She is a non-smoker and non- cervical mucus; impaired transport of ovum
alcoholic beverage drinker. Present and past medical history and PE are and sperm; alters endometrium
unremarkable. • Metabolic
Adverse Effects • Cardiovascular
Questions:
• Reproductive
• What FP method is suitable for her?
• Neoplastic
• What are the mechanisms of action of this method?
• Estrogen component:
• How soon after delivery can this be started?
 Nausea, breast tenderness, fluid
• What are its effects on lipids?
retention
 Minor changes in levels of some
ORAL CONTRACEPTIVE PILLS
vitamins
• Most widely used reversible method → popular  Melasma
• Estrogen + Progestin  Mood changes and depression
• Progestin only (minipill) Metabolic effects  Irregular bleeding
• Currently: low dose formula  Headaches
• Pregnancy rate: 0.3% (perfect use) • Progestin component:
• Failure rate: 8 % (typical use)  Androgenic effects (weight gain,
acne, nervousness)
OCP Formulations  Adverse mood changes and
Fixed Dose • E + P per tablet-same dose tiredness
Combination- • active pills for 21 days  Failure of withdrawal bleeding
monophasic • 7 inert or pill-free days → withdrawal  Irregular bleeding
bleeding  Headaches
Combination • 2-3 different dose of E +P • Estrogen (EE) effects:
phasic
(multiphasic,
• Tablets of same dose given for 5-11 days in
the 21-medication period 51710 fibrinogen  Increased hepatic globulin
production (estrogen) factors V, VIII,
biphasic, • Not found to have advantage over fixed Hepatic Effects X, fibrinogen → thrombosis (venous
triphasic) dose & arterial) angiotensinogen → BP
Daily • low dose progestin elevation
ESTROGEN  Sex hormone binding globulin
progestin/minipill • taken daily at the same time
• no steroid free interval thrombosis (SHBG) reduced by androgens,
• ideal for nursing mothers including androgenic progestins
Estrogen in the • Ethinyl estradiol → Ethinyl estradiol- • Related to dose, potency, structure of
OCP Carbohydrate progestin
• Mestranol → biologically inactive3- methyl-
Metabolism • Higher dose potencies and dose → greater
ether of EE
Effects impairment of glucose metabolism

1
Progestin in the • 19-nortestosterone derivatives
• Gonanes (LNG and derivatives) > Estranes
OCP • Gonanes: PROGESTERONE (Norethindrone and derivatives)
 Levonorgestrel and derivatives
(norgestimate, desogestrel, • Estrogen
 Increase: HDL, total cholesterol, TGs
gestodine) → less androgenic

IF
 Decrease: LDL
• Estranes:
I
Lipid Metabolic • Progestin → will carry more adverse effect
 Norethindrone, norethindrone Effects  Increase: LDL
acetate & ethynodiol diacetate
 Decrease: HDL, total cholesterol,
• C21 progestins:
TGs

III
 pregnane and norpregnanes
Note: Newer derivatives of LNG - less
 Related to progesterone &
androgenic, more lipid friendly – eh ano
derivatives of 17-a acetoxy-
naman??

IILICIG
progesterone
 Medroxyprogesterone acetate • Estrogen
Coagulation  Increase: some coagulation factors
(MPA) & megestrol acetate
Parameter (e.g., fibrinogen) → enhances
 Concerns about carcinogenicity of
Effects thrombosis
C21 progestins delayed the approval
of the depot MPA in the US ESTROGEN • Venous  Dose dependent to embolism
Drospirenone • Neither a 19-nortestosterone nor 17 -a- thromboembolism-risk is greater for
acetoxyprogesterone higher doses (>50mcg) of estrogen
CVS • Myocardial infarction → no evidence of
• Structurally related to spirinoloctone
Effects increased risk of MI from increased risk of
• Antimineralocorticoid/antiandrogenic
activity, progestational activity w/o MI from
• Stroke → conflicting results, no increased
androgenic activity
• DIENOGEST
750mg risk for past users compared to never users

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• No permanent infertility
• HPO suppression is temporary and reversible Non-contraceptive
Reproductive • Length of delay of return to fertility related to
Effects estrogen dose and user age not duration of use
• Pregnancy immediately after discontinuation not
TEMPORARY associated with higher abortion or anomaly rates
• Breast CA → no significantly higher risk
Neoplastic
compared to never users
Effects
• Cervical CA → uncertain, conflicting evidences
• Liver adenoma → high dose mestranol Anti- estrogenic
formulations
• Strong protective effect between OCs &
Endometrial Ca
Endometrial • 1 year of use → 20%
Cancer • 2 years of use → 40%
• 4 years of use → 60%
• Persists for 15 years after stopping use of OCs
• OCPs reduce the risk of ovarian cancer
• Risk decreases by 20 % for every 5 years of use
Ovarian • years of use → 50 % reduction
Cancer • Reduced risk of 4 types of epithelial cancer
• Invasive ovarian CA & borderline tumors
Colorectal • 15 – 20% reduction
CA
GYNECOLOGY
HORMONAL FAMILY PLANNING
OCPS: • Endometrial cancer-protective
• Ovarian cancer-protective
health benefits • Colorectal cancer-protective
OCPS: NON CONTRACEPTIVE HEALTH BENEFITS
• Reduction of menstrual blood loss and less
risk for iron deficiency anemia
• Less incidence of menorrhagia, irregular
menses and intermenstrual bleeding
effects of • Less likely to develop endometrial
progestin adenocarcinoma
• Reduction of incidence of benign breast
diseases
• Less dysmenorrhea and premenstrual
syndrome
Inhibition of • Protection against development of
Ovulation functional ovarian cysts
• Reduction in size of functional ovarian cyst
• Protection vs ovarian cancer
• Risk reduction rheumatoid arthritis
• Protection against PID
Other Benefits • Reduction in incidence of ectopic
pregnancy
• Reduction of bone loss → perimenopause

Note: OCPs

Important Points in Prescribing OCPs

• Adolescent-maturity-HPO
• Acceleration of epiphyseal closure
• After pregnancy:
 mothers not breastfeeding for 6 weeks after delivery → to
avoid thromboembolism

OCP Users: Follow-up

• Lab test not necessary for healthy women
• Nondirected history and BP after 3 months
• Annual visits: BP, weight, complete PE cytology

LONG ACTING HORMONAL CONCENTRATION

• 75ug ethinyl estradiol + 6.0 mg

norelgestromin
• History of vascular disease • One patch per week for three weeks
• Systemic diseases affecting vascular followed by 1 week patch free
system • MOA similar to OCPs
• Smokers older than 35 • Buttocks, upper outer arm, lower abdomen.
• Uncontrolled hypertension CONTRACEPTIVE Upper torso except breast
Absolute • Existing breast and endometrial cancer PATCH
Contraindications • Undiagnosed uterine bleeding
• Elevated triglycerides
• Pregnancy
• Functional heart disease
• Active liver disease
• Heavy smokers (<35 years old)
• Migraines
Relative • Undiagnosed cause of amenorrhea
Contraindications • Depression
• Steroid delivery through vaginal mucosa
• Prolactin-secreting macroadenomas directly into circulation
“I give you questions regarding absolute and relative • 2.7 mg ethinyl estradiol and 11.7 mg
contraindications” etonorgestrel
• Placed in vagina
OCPS: • Highly effective CONTRACEPTIVE for 21 days
Advantages • Readily available VAGINAL RING followed by
• Affordable removal for 7 days
• Easy administration then insertion of
• Many non-contraceptive health benefits new ring
• One size, no fitting
• MOA like OCPs
• Expulsion uncommon

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 GYNECOLOGY
HORMONAL FAMILY PLANNING
• 3 formulas INTRAUTERINE DEVICE / SYSTEM
 DMPA • Copper containing or progestin-impregnated device placed in the
o 150 mg IM or 104 mg SC q 3 endometrial cavity
months • 2 types:
o effective blood levels (>0.2
ng/ml)
o MOAs:
 LNG IUS (5 years) 0
 Copper T 380A IUD (12 years)
Eff Infersency
- Inhibition of ovulation • Spermicide (local sterile inflammation)
- Thinning of endometrium • Impedance of
- Cervical mucus changes Copper T380A: sperm transport and
o Return of fertility → lag time in

I
MOA viability in the
clearing → ovulation- 6-12 cervical mucus
INJECTABLES months (Copper)
 Norethindrone enanthate
 Estrogen
formulations
+ progestin Effaition
Levonorgestrel • Spermicide
Intrauterine • Progestin effects
System (LNG
IUS): MOA
• Any day of the cycle provided the receiver
IUD Insertion is NOT PREGNANT
• No ongoing cervical/vaginal infections
• Highly effective
• Long term (12 years)
• No associated systemic metabolic effects
• Single act of motivation
• Progestin-only containing contraceptives Advantages of • The IUD has the highest continuation rate of
• Inserted sub-dermally under local IUD all reversible methods
anesthesia • No permanent effects on fertility
• MOA same as injectables • LNG-IUS → reduces Menstrual Blood Loss
CONTRACEPTIVE
(thinning of the endometrium)
IMPLANT
• Uterine bleeding (Copper T380A)
Potential • Perforation during insertion
Adverse Effects • Infection
• Complication relating to pregnancy with
IUD-in-utero
• Congenital anomalies → no increased risk
• Spontaneous abortion
ADVANTAGES: • No daily intake of pills • Septic abortion
DMPA AND • Infrequent administration • Ectopic Pregnancy*
INJECTABLES • Maybe appropriate for those with • Prematurity
contraindications to estrogen • Note: "IUDs effectively reduce all
Pregnancy with pregnancies including ectopic ones. Ectopic
BENEFITS: DMPA • Definite risk reduction: IUD-in-Utero
 PID and salpingitis pregnancy is reduced by 90% compared to
 endometrial cancer those without contraception. But if
 iron deficiency anemia pregnancy does occur with the IUD in place,
 sickle cell problems the risk of it being ectopic increases
 Ovarian cysts threefold."
 Dysmenorrhea • Pregnancy or suspected pregnancy
 Endometriosis • Acute PID
 Epileptic seizures • Postpartum endometritis or infected
 Vaginal candidiasis abortion in the last 3 months
Contraindication • Known or suspected uterine or cervical CA
DISADVANTAGE • Unscheduled or irregular uterine bleeding
AND ADVERSE to IUD • Genital bleeding of unknown origin
• Need for minor surgical procedure to insert
EFFECTS: and remove device • Untreated acute cervicitis
IMPLANTS • Operative site-potential site for infection • Previously inserted IUD that has not been
(uncommon) removed
DISADVANTAGES • Unshed or irregular bleeding
AND ADVERSE: • Delayed resumption of ovulation STERILIZATION
DMPA • Weight gain – unclear/obese X • Permanent contraception
• Depression and mood changes • Fallopian tubes, vas deferens
• Headache – not enough studies; not a • Reversal is difficult, success rates variable
contraindication to its use • Pregnancy rates: extent of damage, surgeon's expertise
• Metabolic effects → insignificant effects
on lipid, glucose and protein metabolism • Short outpatient procedure
lowers HDL but DMPA not demonstrated to • Local anesthesia
accelerate atherosclerosis • Sterility after 14-20 ejaculations
• Bone loss → DMPA suppresses • Note: Two aspermic ejaculates required
• Estrogen → bone remodeling but is • Complication:
reversible (Bisphosphonate not for low VASECTOMY  Hematoma
BMD)  Sperm granulomas
• Neoplastic effects → Does not affect  Spontaneous Hematoma
incidence of breast, cervical and ovarian  Sperm granulomas
 Spontaneous

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 GYNECOLOGY
HORMONAL FAMILY PLANNING

• Disadvantage
 Difficult and meticulous reversal or
reanastomosis procedures with success
rate only 50%
• 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)
• Complications:
BILATERAL
 Bleeding
TUBAL
 Infection
LIGATION
 Anesthetic complications
 Bowel injury (laparoscopic
electrocoagulation)
 Uterine perforation and device expulsion
(microinserts)

END

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GYNECOLOGY
FAMILY PLANNING (NON-HORMONAL)
DR. AVSJ
OLFU • FUMC  COLLEGE OF MEDICINE
Reference: COMPREHENSIVE GYNECOLOGY 7th Ed. Lobo | Gershenson | Lentz Valea

OBJECTIVES: BARRIER METHODS

• Types of Family Planning
• Preparations
• Mechanism of actions DIAPHRAGM
• Effectivity • Thin, dome shaped membrane of latex rubber or silicone w/ a
• How to use
• Advantages & Disadvantages flexible spring modeled into the rim
• Adverse effects • Carefully fitted for size

TYPES OF FAMILY PLANNING • Cervical os covered A

• Largest size that does not cause discomfort

• Reversible Method • Used with spermicide

 temporary prevention of fertility and includes temporary • Left in place for 8 hours after last coitus
prevention of fertility and includes • Pregnancy rate:
• Permanent Method  perfect use: 4 to 8 %
 Terminal  typical use: 13 to 17 %
• Safe, reversible
Note: Methods of Contraception • Married, motivated women
• REVERSIBLE Methods • Failure rates decrease with age and duration of use
 Spermicides • Adverse Effects:
 Barriers  Urinary tract infections
 Oral Contraceptive pills  Vaginal epithelial ulcerations
 Long-Acting Hormonal Hormonal  Caya: FDA approved
 Contraception
• PERMANENT
 Vasectomy
 Bilateral Tubal Ligation

• Contraceptive Effectiveness
 Typical Use Effectiveness
 Perfect Use Effectiveness
 Contraceptive Failure Rate
o Number of pregnancies per 100 Number of
pregnancies per 100
• Pearl Index
CERVICAL CAP
• Cup shaped rubber device
that fits around the cervix
(diff sizes)
• Should be fitted to CX
REVERSIBLE METHODS • Used with spermicides,
placed any time before
SPERMICIDES intercourse
• Gels, foams, creams, Gels, foams, creams, suppositories • left in place for at least 8hrs
• Active agent → nonoxynol-9 – kills or immobilizes sperms after last coitus
• Used with barriers • Failure rates similar to
• Pregnancy rate:
 Typical use: 29%
Nonoxynol 9 diaphragm
• Normal cervical cytology required
 Perfect use: 18% • Pap test 3 months after
• No increased risk for congenital malformations or chromosomal • Cervical cap & diaphragm → may decrease the risk of cervical
anomalies dysplasia& cancer
• Increased risk of vaginal erosions & HIV transmission • Advantages:
• Contraceptive Sponge Does not
protect M CinindCA
 cylindrical piece of soft polyurethane with 1 mg of nonoxynol
 Safe and reversible
 Good continuation rates
9  Placed longer than diaphragm
dysplasia

E
 Effective for 24 hours  More comfortable
 Pregnancy rate: • Adverse effects:
o perfect use: 9 %  If left in place > 48 hours:
o typical use: 16% o mucosal ulcerations
o unpleasant odor
o infection
o adverse effects on cervical tissue

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 GYNECOLOGY
FAMILY PLANNING (NON-HORMONAL)
MALE CONDOM  Draw a line 0.05-0.1° C above highest of these 10
• Latex, polyurethane FDA temperatures. This line is called the cover line or
• Most effective contraceptive method to prevent transmission of temperature line
STDs (latex, polyurethane)
• Pregnancy rate:
 Latex – 5.4%
 Polyurethane – 9-10.8%, 15%-typical
• Males with multiple sex partners
• Correct use and careful Correct use and careful
• Advantages
 Safe, reversible
 Prevent STD transmission
 Highly effective for motivated user

CERVICAL MUCUS / BILLING'S METHOD

• Recognition of changes in cervical mucus consistency
• Abstinence or barrier on the first day of copious slippery mucus and

E
FEMALE CONDOM until 4 days after the last day when the characteristic after the last
• Loose fitting soft polyurethane sheath with two flexible rings day when the characteristic
• Inner and outer rings  "wet" → ABSTAIN
M s
• Pre-lubricated  "dry" → SAFE PERIOD
gg the
• Single use only failurerateus
• Typical use failure Iggy Symptothermal Method
• Calendar + cervical mucus → to establish first day of fertile period
• Pregnancy rate: 21 %
• Advantages: Genital herpes • Temperature method to establish last day
 Reduction of STD transmission especially if used with
spermicides
 Protection against salpingitis and cervical neoplasia

NATURAL FAMILY PLANNING

Periodic Abstinence
• Avoidance of coitus at the time ovum can be fertilized
• Highly motivated couple
• Four methods:
 Calendar/Rhythm
 Temperature
 Cervical mucus method
 Symptothermal Periodic Abstinence
Advantages Disadvantages
Calendar/Rhythm • Safe, reversible, affordable • Require highly motivated
• Fertile period based on length of cycles • No pharmacologic side couple
• Shortest cycle subtracts 18 and longest cycle subtract 11 effects • Higher failure and
• Couple abstains during the estimated fertile period discontinuation rates
• Couple abstains during the estimated fertile period • Long period of abstinence
• Regular cycles (calendar)s
Calendar
• If shortest cycle is 27 and longest cycle is 31, what is the woman's Lactational Amenorrhea Method (LAM)
fertile period? • Prolactin inhibits gonadotropin pulsatility → nursing women remain
 COMPUTE!!! → Fertile period is from days 9 to 20 and amenorrheic after giving birth
couple should abstain or use barriers at this time • Higher frequency, & longer duration of nursing & night nursing →
anovulation and amenorrhea
Basal Body Temperature Method (BBT) • Criteria for success of LAM:
• Daily monitoring of temperature
6 mouths
1
 continuous amenorrhea
• Coitus NOT done or a barrier is used from cessation of menses until  exclusive breastfeeding (no supplements) for 6 months)
3rd consecutive day of elevated consecutive day of elevated • Failure rate (first 6 months): <2%
• No longer used alone
TempDue to Progesterone • Plan for alternative contraceptive if conditions for success
• With LAM no longer present
Note: Client Instructions for BBT Method
• Thermal Shift Rule: PERMANENT METHOD
 Take temperature at about same time each morning
(before rising) and record temperature on chart provided Sterilization
by NFP instructor. • Permanent contraception
 Use temperatures recorded on chart for first 10 days of • Fallopian tubes, vas deferens
menstrual cycle to identify highest of "normal, low"
• Reversal is difficult, success rates variable
temperatures (i.e., daily temperatures charted in typical
• Pregnancy rates → extent of damage, surgeon's expertise
pattern without any unusual conditions)
 Disregard any temperatures that are abnormally high
due to fever or other disruptions

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thimconseuthEDAnnotEMI
 GYNECOLOGY
FAMILY PLANNING (NON-HORMONAL)
Vasectomy
• Short outpatient procedure
• Local anesthesia
• Sterility after 14-20 ejaculations – not usually, time consuming
• Two aspermic ejaculates requires – most done compare to 14-20
ejaculations

• Complications:
 Hematoma
 Sperm granulomas
 Spontaneous reanastomosis
• Disadvantage
 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 Most effective
and least destructive -
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)
• Complications:
 Bleeding
 Infection
 Anesthetic complications
 Bowel injury (laparoscopic electrocoagulation)
 Uterine perforation and device Uterine perforation and
device

End

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