KONTRASEPSI

Dr Adi Setyawan Prianto Sp.OG, KFER

LABORATORIUM OBSTETRI DAN GINEKOLOGI

Sub Divisi Fertilitas Dan Endokrinologi Reproduksi
Fakultas Kedokteran dan Ilmu-Ilmu Kesehatan UNSOED
PURWOKERTO 2013
 Epidemiology
• 98% of women who had sexual intercourse used at
least one method of contraception.1
• Oral contraceptive pill is the most popular form of
contraception: 11.6 million US women in 2002.1
Nineteen percent of women ages 15-44 (CDC’s
National Center for Health Statistics).
• Followed by female sterilization, condoms, male
sterilization, and other methods.1
• 49% of pregnancies were unintended in 2001.2
– 1. Kaiser Family Foundation. Women’s health care providers’ experiences with emergency
contraception. Kaiser Family Foundation. June 2003.
– 2. Disparities in Rates of Unintended Pregnancy in the United States. 1994 and 2001. Finer
LB, Henshaw SK, Perspectives on Sexual Reproductive Health, 2006:38:90–96. Health,
2006:38:90–96.
Women’s current use of modern
contraceptive methods

IUD
7% Injectables
40%
Male condom
5%
Monthly pill
15% Female
Daily pill sterilisation
24% 8%
Other
modern
methods
1%
 Introduction
• Approximately 50% of all pregnancies in the United
States are unintended
– Among women who had an unintended pregnancy in
2001, 52% had not been using a method of
contraception during the month of conception
– In 2001, 42% of unintended pregnancies ended in
abortion
• As internists, we routinely prescribe teratogenic
medications to women of childbearing age
– Examples: statins, ace inhibitors, coumadin, tetracycline,
doxycycline, streptomycin, phenytoin, valproic acid,
carbamazepine, lithium
 Objective
 To improve rates of contraception counseling in our clinic,
particularly in women of child-bearing age on teratogenic
medications.
 In order to do this, today we will discuss the advantages,
disadvantages, side effects and contraindications of the
following contraceptive methods:
Barrier Methods
Oral Contraceptive Pills
Injectable Contraceptives
Contraceptive Patch
Vaginal Ring
Intrauterine Devices
Implantable contraception
 What do women want from the
ideal contraceptive method?
• Highly effective
• Prolonged duration of action
• Rapidly reversible
• Privacy of use
• Protection against STD
• Easily accessible
 Contraceptive methods and failure rate in
first year with typical use
• Tubal ligation 0.3-0.5%
• Vasectomy 0.1%
• Multiload/Cu-T380A <1%
• Inj Depoprovera <1%
• OCP <1%
• Condom 15-25%
• Fertility awareness >25%
• withdrawl Method 25-35%
• No contraception 85%
 Review: the menstrual cycle
• Pulsatile GnRH (hypothalamus)
• LH and FSH (anterior pituitary)
– LH stimulates:
• Ovulation (36 hrs after LH
surge)
– FSH stimulates:
• Folliculogenesis
• Estradiol production
• Estradiol and progesterone
(ovaries)
– Estradiol:
• Initial negative feedback on
hypothalamus and pituitary
• Endometrial proliferation
• When high enough long
enough, switches to positive
feedback resulting in LH
secretion
– Progesterone:
• Elevation indicative of
ovulation
• “Pro-pregnancy”
• Inhibits LH & FSH
 Contraceptive Counseling
• Two interventions have shown efficacy in helping
patients become successful contraception users:
– Use an effective method of counseling upon initiating a
method and during follow-up visits
• Explain how the method works (and if it protects against STDs)
• Describe how to switch methods
• Discuss side effects
• Warn patients about potential adverse reactions
– Consider the patient’s choice of contraception; this is
linked with continued use of a method
 How does hormonal contraception
work?
• Estrogen:
– Prevention of estrogen surge, which prevents LH surge → no
ovulation
– Suppression of gonadotropin secretion during follicular
phase, preventing follicular maturation and preventing
ovarian hormone production
• Progesterone:
– Creates thick cervical mucus to hinder sperm penetration
– Impairs normal tubal motility and peristalsis

» Martin KA, Barbieri R, Up To Date: Overview of the use of estrogen-progestin

contraceptives. Available online. (Accessed Jan 30 2007).
Combination hormone contraceptives
halt ovulation

No egg = no pregnancy
 Hormonal Contraception Options
• Combined oral contraceptives (COC)
– (Mestranol)→ethinyl estradiol
• Estrogen level has decreased from 100 mcg/day → as low as 20 mcg/day
• Most women should get no more than 35 mcg/day ethinyl estradiol
• 50 mcg estrogen may be appropriate if:
– Spotting, absence of bleeding, or dysfunctional uterine bleeding; Acne; Ovarian
cysts; Endometriosis; Drug interactions (induction of Cytochrome P450)
– Progestins
• Most potent: desogestrel, levonorgestrel, norgestrel
• Least potent: norethindrone
• Most androgenic: norgestrel > norethindrone & ethynodiol
• Least androgenic: desogestrel & norgestimate → may ↓ risk of MI
» Hormonal contraception. Pharmacist’s Letter/Prescriber’s Letter 2006; 22 (8):220809.
 Hormonal Contraception Options cont’d.

• Monophasic vs. biphasic vs. triphasic

– Biphasic and triphasic thought to more closely mimic fluctuations in estrogen
and progesterone levels during the menstrual cycle; ↓ dose-dependent
adverse effects of progestin
– Recent Cochrane reviews conclude that choice of progestin is more important
than phasic formulation
• Progestin-only pills (POP)
– Women who are breastfeeding-can be started immediately postpartum
– Considered safer in women w/ migraines, hx of thromboembolic disease,
poorly controlled HTN w/ vascular disease or >35 yrs, diabetes w/ vascular
disease or >35 yrs, SLE w/ vascular disease, hypertriglyceridemia, smoker
over 35 yrs of age, CAD, CHF, cerebrovascular disease

» Hormonal contraception. Pharmacist’s Letter/Prescriber’s Letter 2006; 22 (8):220809.

 Noncontraceptive health benefits of
combined oral contraception
• Relief symptoms associated with menstruation : heavy periods, painful
periods and irregular bleeding.

• Have improvement in acne and hirsutism.

• To treat menorrhagia or symptomatic endometriosis

• A long lasting reduction in

the risk of developing cancer of the ovary and the endometrium.

• Benign breast disease (BBD), bone health and colon cancer are
less clear and merit further investigation.
 Other benefits (lowered risk or incidence):

• Dysmenorrhea
• Iron deficiency anemia
• Ectopic pregnancy (COC pill only)
• Ovarian cysts (higher dose estrogen pills only)
• Ovarian cancer
• Endometrial cancer
• Increased bone density
• Acne
– Ortho Tri-Cyclen and Estrostep FDA-labeled for treatment of acne*

» Martin KA, Barbieri R, Up To Date: Overview of the use of estrogen-progestin

contraceptives. Available online. (Accessed Jan 30 2007).
» *Hormonal contraception. Pharmacist’s Letter/Prescriber’s Letter 2006; 22
(8):220809.
 Combined Oral Contraceptive Pills
Advantages
• Fertility returns rapidly
• Bleeding is decreased
• Greater cycle predictability
• Decreased risk of benign breast
disease, PID, ovarian and
endometrial cancers
Disadvantages
• Increased risk of stroke, acute MI,
venous thromboembolic disease
• Increased risk of hepatic
adenoma, cervical cancer, breast
cancer
• Do not protect against STDs
• When used with antibiotics or
anticonvulsants, efficacy may be
decreased
Risk Factors
 Combined OCPs: Side effects
• Nausea, vomiting • Mood changes
• Headache • Decreased libido
• Weight gain • Increased triglycerides
• Dizziness • Severe depression
• Mastalgia • Spotting, breakthrough
• Melasma bleeding
• Hypertension
 Combined OCPs: Contraindications
• Smoker of age > 35
• History of breast cancer
• Abnormal vaginal bleeding
of unknown etiology
• Cerebrovascular disease
• Congenital hyperlipidemia
• Ischemic heart disease
• Migraine
• Diabetes >20 years OR with
severe vascular disease,
nephropathy, retinopathy,
neuropathy
• Major surgery with
prolonged immobilization
• Severe hypertension
• Thrombophlebitis,
thromboembolic disease,
known thrombogenic
mutations
• Liver disease
 Side Effects
Too much ESTROGEN Nausea, bloating, breast
tenderness, ↑ BP, melasma,
headache
Too little ESTROGEN Early/mid-cycle breakthrough
bleeding, ↑ spotting,
hypomenorrhea
Too much PROGESTIN Breast tenderness, headache,
fatigue, changes in mood

Too little PROGESTIN Late breakthrough bleeding

Too much ANDROGEN ↑ appetite, wt gain, acne, oily skin,

hirsutism, ↓ libido, breast
tenderness, ↑ LDL, ↓ HDL
Hormonal contraception. Pharmacist’s Letter/Prescriber’s Letter 2006; 22
(8):220809.
 Plan for Missed Pills
Contraceptive Technology,18th Revised edition, by Robert Hatcher, MD.
 Mechanism of Action: Abortifacients
• Mifepristone (aka RU-486)
– It is a competitive receptor antagonist in the presence of progesterone
at the progesterone receptor.
– It causes the decidual degeneration which leads to trophoblast
detachment.
– Results in decreased production of Human chronic gonadotropin
(hCG), which causes decreased production of progesterone by the
corpus luteum.
– Since pregnancy is dependant on progesterone production by the
corpus lutenum, pregnancy is terminated.
– In addition it increases prostagladin release from the uterine lining,
increasing uterine contractions and enhances the uterus’ sensitivity to
prostagladin.
 Mechanism of Action: Abortifacient
• Methotrexate
– Blocks enzyme necessary for DNA synthesis, which
inhibits the growth of placental trophoblastic
cells.
 Mechanism of Action: Abortifacient
• Misoprostol
– Synthetic protaglandin E1 analogue.
– Used in combination with Mifepristone and
Methotrexate.
– Softens and dilates the cervix.
– Binds to myometrial cells to cause uterine
contractions which cause expulsion of the
embryo.
INJECTABLE CONTRACEPTIVES

Depo-Provera
 Depo-Provera
• Progestin-only: Depo-medroxyprogesterone
acetate (DMPA) 150 mg IM every 12 weeks
• Alters endometrial lining, thickens cervical
mucus and blocks LH surge preventing ovulation
• Failure rate 0.3% with perfect use, 3% with typical use.
 Depo-Provera
Advantages
• Efficacy is not altered by varying
weight nor use of concurrent
medications nor
sickness/diarrhea
• Decreased anemia,
dysmenorrhea
• Decreased risk of endometrial
and ovarian ca, PID, ectopics
• Safe for use in breast-feeding
mothers
• Does not produce serious side
effects of estrogen
Disadvantages
• Involves injections and
remembering to visit MD every 3
months
• Persistent irregular bleeding
• Delayed return to fertility
• Weight gain-about 5 lbs in first
year.
• Depression
 Side effects of Depo-Provera
• Edema, thromboembolic disorders
• Nausea, vomiting, diarrhea, abdominal pain
• Hot flashes, decreased libido, menstrual changes, breast
tenderness, galactorrhea
• Weight gain
• Headache, insomnia, dizziness, depression, fatigue, nervousness
• Rashes, alopecia, acne, urticaria, pruritus
• Injection site reactions
• Can cause decreased bone mineral density, but this is not
associated with increased fracture risk, is transient and
reversible upon discontinuation.
 Contraindications to Depo-Provera

• Known or suspected pregnancy

• Undiagnosed vaginal bleeding or missed abortion
• Known or suspected malignancy of the breast
• Active thrombophlebitis, current thromboembolic
disease, or cerebral vascular disease
• Liver dysfunction or disease
 Intrauterine Devices

• Copper T 380A
• Mirena
 IUDs
Copper T IUD
• Causes migration of WBCs into
the uterine cavity resulting in
phagocytosis of spermatozoa
• Copper ions seem to have direct
toxic effect on spermatozoa
• Can be left in place for 10 yrs
• Bleeding: Increases flow 50%,
regular periods, 7-12% remove
for bleeding and/or pain at 1 year
• Failure rate w/ perfect use 0.1-
0.6%, typical use 0.1-0.8%
Mirena
• Releases 20 mcg LNG per day into
uterine cavity for 5 years
• Inhibits fertilization: anovulation,
thickens cervical mucus, inhibits
sperm and ovum motility and
function
• Can be left in place for 5 years
• Bleeding: Decreases flow 90%,
irregular periods w/ spotting,
20% amenorrheic at 1 year, 7%
remove for bleeding within 1 year
• Failure rate w/ perfect use 0.1-
0.6%, typical use 0.1-0.8%
 Multiload /Cu-T 380 A

• Most misunderstood contraception

• It has a small T shaped body which bears a coil of copper wire on it.
• Prevents pregnancy by interference with sperm transport ,Ovum transport
• ,fertilization & implantation

• Incidence of complications
- Heavy periods in 10% cases, can be controlled with medicine, more common
with wrong case selection
• -Perforation 0.5 in 1000 cases (WHO 1987),very little chances in experienced
hands
• Timing of insertion-
• Immediately after periods
• 6 weeks after normal delivery
• 6 weeks after caesarean section
• Immediately after early abortion
• Lactational Amenorrhoea after reasonably excluding pregnancy
• As emergency contraception
• Fertility returns immediately after discontinuation

CU-T 380 A IS BEST IUCD according to W.H.O in the world. It has a

failure rate like permanent method of tubal ligation. It can be kept
as long as 10 years.
Even those with previous caesarean can go for it.
 MIRENA
• Mirena is a small flexible plastic device, inserted inside the uterus,. It slowly
releases progesterone hormone, which stops ovulation,alters the cervical mucus
&changes the lining of uterus.
• Things to know about Mirena
-99.9% effective in preventing pregnancy
-provides lower & steadier hormones than pills
-lasts for up to 5 yrs or less if you choose
-easily removed when you want it to be
-won’t cause significant weight gain
-May also help shorten,lighten or even eliminate periods
----.Imp safety information about Mirena-
-Designed for women who have had at least one child & have no risk of ectopic
pregnancy or PID
-Ovarian cyst may occur & typically disappear
-Complications may occur from placement
-Missing periods or irregular bleeding is common in first few months, followed by
shorter,lighter periods
 IUDs
Advantages
• Long-term
• Reversible
• Most cost-effective
• No systemic side effects
• Mirena only: decreased
menorrhagia, dysmenorrhea,
anemia
• Decreased rate of ectopic
pregnancies overall*
Disadvantages
• Increased risk of PID (only at
insertion-1/100)
• Risk of perforation with insertion
(1/1000)
• Cramping and pain at insertion
• May be expelled unnoticed
• No STD protection
• REQUIRES COUNSELING, HISTORY,
PELVIC EXAM, SCREEN FOR
GONORRHEA/CHLAMYDIA and
PAP SMEAR**
 IUD Side Effects
• Mood changes
• Acne
• Headache
• Breast tenderness
• Nausea
• With Copper T: cramping, increased bleeding
 Contraindications to IUDs
• High risk for STDs
• Current cervicitis or PID
• Known or suspected pregnancy
• Uterine anatomy interfering w/ placement
• AIDS, not doing well on ARV therapy
• Mirena only: Current DVT
• Copper only: Allergy to copper or Wilson’s dz
• Gynecologic or breast malignancy
• Unexplained vaginal bleeding
 Immediate postpartum insertion for
intrauterine devices
• Immediate postpartum insertion (within 10 minutes
of delivery of the placenta) of copper-bearing
intrauterine devices (IUDs) is generally safe and
effective, although compared with interval insertion
it carries a higher risk of expulsion. Immediate
postpartum IUD insertions can be implemented in
most developing-country settings and any available
copper-bearing IUD can be used for this purpose.
IMPLANTABLE CONTRACEPTION
Implanon
 Implanon
• Progestin-only
(etonogestrel) implanted
contraceptive rod
• Implanted subdermally in
upper arm
• Lasts 3 years
• Blocks LH surge, preventing
ovulation. Thickens cervical
mucus. Alters endometrial
lining.
• Failure rate 0.1%
 Implanon
Advantages Disadvantages

• Rapid return to fertility • Does not protect against

• Lasts 3 years STDs
• Safe to use during breast- • May be less effective in
feeding overweight women
• Complications at the time of
insertion or removal, such
as scarring, bleeding,
infection
 Implanon: Side effects
• Irregular bleeding and dysmenorrhea
– No consistent bleeding pattern-amenorrhea, infrequent
bleeding, prolonged bleeding
• Acne
• Weight gain-about 12% of patients
• Headache
• Mood swings
• Depression
• Decreased libido
• Breast/abdominal pain
 Contraindications to Implanon
• Known or suspected pregnancy
• Active venous thromboembolic disease
• Active liver disease
• Undiagnosed vaginal bleeding
• Known or suspected breast cancer
• Progesterone dependent tumors
• Allergy to any components
Postpartum Contraception
Counseling
What is different about contraception
in postpartum period?
• breastfeeding

• hypercoagulable state

• different contraceptive needs

 Breastfeeding Physiology
 Pregnancy
 Prolactin secretion in pregnancy -> breast growth, milk biosynthesis
 Progesterone (and estrogen) ->interferes with prolactin binding, inhibits
lactation
 Birth
 Rapid decline placental progesterone -> initiation of lactation
 Suckling -> oxytocin release -> contraction of the myoepithelial cells -> milk
ejection
 Day 2-4 postpartum,
 Steroid hormones cleared -> maintenance of milk production
 High serum prolactin -> inhibits pulsatile GnRH -> prevent ovulation ----->
maintained?
 Lactational Amenorrhea
– Ovulation within 3 months in exclusive breastfeeders,
– As early as 3-6 weeks in women who are not exclusively
breastfeeding
– May precede menstruation

• EBM
– < 2% “failure rate” in women exclusively or ‘mostly’
breastfeeding (DEF - feeding both night and day,
ammenorheic, infant less than 6 months old and
receiving >90% nutrition from breastmilk) (WHO)
 LAM
• Clinical Judgment
– Menstruation/ovulation is unpredictable
– Duration of breastfeeding
– Resumption of sexual activity
 Depo-Provera-
Progesterone only injection

• Breastfeeding (Hannon, 1997)

– NON-sig effect on duration or frequency of lactation
– NON-sig effect on timing of introduction of formula

• Adolescents (Templeton 2000)

– 55% Depo vs 24% OC users continued method at 1 year.
– Total incidence of repeat pregnancy 10.6% at 1 year.
– 24% in OC users and 2.6% in Depo users pregnant at 1
year.
Emergency Contraception
and Adolescents
 Adolescents Need EC
• The U.S. has one of the highest teen pregnancy rate
in the industrialized world.

• 82% of teen pregnancies are unplanned

Teen Pregnancy Rates Worldwide, 2000

Per 1000
 Sexual Assault and EC
• >50% of all rapes occur in young women
under 18 years old
• For teens, 5.3% of rapes lead to a pregnancy.
• Emergency contraception should be offered to
all survivors of sexual assault.
 U.S. Pregnancies:
Unintended vs. Intended
Intended Unintended
51% 49%:

Unintended
births (22.5%)

Elective abortions
(26.5%)

Henshaw SK. Fam Plann Perspect. 1998;30:24-29. www.contraceptiononline.

 Consequences of unwanted pregnancy

Unwanted pregnancy has significant consequences for women and

their families, including:

Unwanted and early marriage

Constrained opportunities for education or employment
Social stigma for unmarried women/girls
Additional strain on family resources for food, education, and
health care
Unsafe abortion, which may result in long-term illness, emotional
distress, and death
 Human Error

• Inconsistent contraceptive use

• Incorrect contraceptive use

• Unplanned intercourse
 Emergency Contraception
• Levonorgestrel pill is available
• Single tablet has to be used within 72 hours of
unprotected coitus. It is effective to the tune
of 90%.
• Every women & adolescent girl should know.
However emergency contraceptive can not
replaced regular contraceptive for people who
are sexually active.
 Brand Name Levonorgestrel ECPs

• Dedicated Product: Plan B One-Step

– FDA approved July 2009
– ingle tablet formulation 1.5mg of levonorgestrel
• Original Plan B
– Two tabs of 750 mcg levonorgestrel
– Approved in 1999
– Approved for OTC 18 and older in 2006
• Both are now OTC for 17 and older
Contraception for women aged
over 40 years
Conception vs infertility
• As age increases, fertility
decreases in women
• Declines to lesser degree in
men

• At 40-44, 36% likelihood of

spontaneous pregnancy

Source: Management of the

Infertile Woman, Helen A
Carcio
 Pregnancy outcomes
• Pregnancy later in life is associated with worse reproductive
outcomes:
• Maternal
– Gestational diabetes
– Placenta previa
– Placental abruption
– Caesarean section
• Fetal
– Chromosomal abnormalities (eg Trisomy 21)
– Miscarriage
– Low birth weigh
– Preterm delivery
– Increased perinatal mortality
 Women’s choice of method
• Aged 40-44y, 75% used at least 1 method
• Aged 45-49y, 72% used at least 1 method

• Most commonly used methods:

– Sterilisation (male and female)
– Male condom
– Pills
– IUD
Office for National Statistics, Contraception and Sexual Health
Survey, 2008-9
 Health Benefits of Combined Hormonal
Contraception
• Dysmenorrhoea and cycle control
• Menopausal symptoms
• Bone health
• Ovarian and endometrial cancer
• Benign breast disease
• Colorectal cancer
 Health Risks with CHC
• Breast cancer
– Annual risk of breast cancer increases with increasing age
– There may be a small additional risk of breast cancer with
CHC use
– Any risk reduces to no risk 10 years after stopping CHC
– Current breast cancer UKMEC 4
– Family history of breast cancer UKMEC 1
– BRCA 1 and 2 mutation carrier UKMEC3- expert clinical
judgement and/or referral to specialist provider
 Health Risks with CHC
• Cervical cancer
– Small increased risk (invasive and in situ)
– Long term users can be reassured that benefits
outweigh risks
– Risk of invasive cancers declines after stopped
using (after 10 years, return to never user risk)
– HVP and condom use
 Health Risks with CHC
• Venous thromboembolism (VTE)
– VTE is rare in women of reproductive age
– VTE risk increases with increasing age
– Relative risk of VTE is increased with use of the
COC
– Uncertainty about the risks of patch and risks of
CVR unknown
 Health Risks for CHC
• UKMEC categories for CHC
• Stroke (CVA including TIA) UKMEC 4
• Hypertension
– Adequately controlled hypertension UKMEC 3
– Consistently elevated blood pressure
• Systolic >140-159mmHg or diastolic >90-94mmHg UKMEC 3
• Systolic ≥160 mmHg or diastolic ≥95mmHg UKMEC 4
– Vascular disease UKMEC 4
• Multiple risk factors for CV disease (older age,
smoking, diabetes, obesity, hypertension) UKMEC
3/4
 Sexually transmitted infections
• STIs are not confined to younger people
• There has been an increase in diagnoses in
over 40 year olds
• Condoms protect against STIs even after
contraception no longer required
 Stopping contraception
• In general contraception may be stopped at
the age of 55 years
– Advice need tailored to the individual
• If having regular menstrual cycles at 55 y-
should continue on some contraception
 Unsafe abortion

Unsafe abortion is the termination of a pregnancy

carried out by someone without the skills or training
to perform the procedure safely, or in a place that
does not meet minimal medical standards, or both.

Approximately 20 million unsafe abortions take

place each year. More than 200 women die every
day from complications of unsafe abortion. 99.9%
of abortion-related deaths and complications occur
in the developing world.
unwanted pregnancy and unsafe abortion
(9)
Thank You