CONTRACEPTION

.
 “Any artificial method that can be used to prevent
conception when the female doesn’t want to conceive is
known as contraception.”

 Correct and consistent use of effective methods

contraception can prevent most unintended pregnancies.
 Many women who present with an unintended
pregnancy have used a contraceptive method but it’s
usually the one with low effectiveness (e.g. condom) or a
method that has been used inconsistently or incorrectly
( pills).
 Most effective methods of contraception are the “ long-
acting reversible methods of contraception” (LARCS)
such as Cu-IUD and LNG-IUS.
General mechanism of action of
contraceptives:
Usage of contraception can be used to prevent pregnancy by
following ways:
o Preventing ovulation: combined hormonal contraceptives,
oral emergency contraceptive pills, lactational amenorrhea
are beneficial
o Preventing sperm from reaching the oocyte : male and female
sterilization
o Poisoning the sperms by using spermicides
o Preventing sperm from entering the vagina :condoms are
used, avoidance of intercourse during ovulation period
o Blocking the sperm pathway if it has entered the female
genital tract: diaphragms , vaginal caps
o Preventing implantation of embryo : Cu –IUD, LNG-IUS
Pre – requisites before using contraceptives:
 Provide appropriate guidance regarding how to use the
contraceptive method which you’re suggesting
 Tell female about the failure rate i.e. chance of pregnancy
occurring with that contraceptive method and it’s
effectiveness.
 Mention side effects of the proposed contraceptive method.
 Tell the female if there are any additional health benefits of the
contraceptive she’s going to use.
 Tell her about when her fertility will return after she has
stopped using the contraception.
 Tell her to visit if she had forgotten to take her contraceptive
pills more than 3 times simultaneously and if she’s using any
other contraceptive then guide her as to when she needs to
come for a review.
 Methods of contraception
1.Combined hormonal contraception ( CHCs ):
Contain a combination of synthetic estrogen and progestogen.
They are available as :
 Oral contraceptive pills
 Vaginal rings
 Transdermal patches
Note that they are not given in injectable forms .
a) Oral contraceptive pills :
Mechanism of action of CHCs :
 When we give estrogen and progesterone exogenously in form of CHCs ,
they’ll maintain a basal level ( neither too low nor too high)of these
hormones in your blood
 This’ll result in negative feedback inhibition of pituitary gland resulting in
decreased release of FSH and LH
 This’ll result in decreased release of estrogen and progesterone
endogenously.
 LH surge will not occur as a result of which there will be no
ovulation.
 Oocytes won’t be released so even if sperms enter the female
genital tract , fertilization won’t occur
Even though high estrogen levels cause LH surge but while
using the pill estrogen levels are maintained at such an
optimal level that they don’t rise enough to cause LH surge so
there’s no risk of ovulation occurring.
Non contraceptive actions of CHC pills :
 Estrogen present in the pills causes hypertrophy of
endometrial epithelium + glandular proliferation.
 Progestogen increases the secretory activity of endometrium
and also increases tortuosity of endometrial vessels and
causes vasodilation
Composition of CHCs pills:
 Most of the CHC pills are “ low dose “ and contain ethinyl
estradiol.
 Some newer pills contain oestradiol valerate or oestradiol
hemihydrate.
 The progestogens used in these pills are referred to as ;
2nd generation : levonorgestrol, norethisterone
3rd generation : gestodene desogestrel
4th generation : drospirenone, dienogest
The 3rd and 4th generation ones have less androgenic activity
but have a greater risk of venous thromboembolism
The 2nd generation ones have low risk of thromboembolism
and are more commonly preferred in form of pills especially
Levonorgesterol.
Preparation forms of CHC pills :
 Traditional preparations contain 21 pills followed by a 7 day pill
free interval or patient is given 7 placebo pills that are usually iron
tablets.
 While patient is taking the CHC pills she doesn’t experience any
menstrual bleeding .
 Due to action of progestogens and estrogen normal endometrial
hypertrophy and glandular proliferation keeps on occurring ,which
obviously needs to be shed off just like in normal menstrual periods.
 For this purpose a 7 day pill free interval is given during which the
“Withdrawal bleed “ occurs .
 Sometimes you give 24 tablets, no placebo pills with 6 day pill free
interval.
 Women who experience dysmenorrhea or headaches during the pill
free intervals are advised to do “ Tricycling” i.e. they take 3 packets
of CHC pills consecutively and then take a pill free interval to shed
the endometrial lining and avoid recurrence of above mentioned
symptoms.
b) Patch and ring forms of CHCs:
TRANSDERMAL PATCH :
It is applied to skin of lower abdomen, buttock or arm for 7
days but can be applied to any skin covered srea except for
breast.
Combined hormonal transdermal patch releases :
Ethinyl estradiol : 33.9 microgram/day
Norelgestromin : 203 microgram /day
The regimen involves application of patches for 21 days total
meaning patient will have to change the patch 3 times within
this period followed by a 7 day pill free interval.
VAGINAL RING :
• Low dose combined hormonal method.
• Flexible ring of 54mm diameter is inserted.
• The ring releases:
15 microgram ethinyl estradiol / day
.

120 microgram etonorgesterol /day

• Patient can insert the ring by herself for 21 days after which
it’s removed for withdrawal bleed to occur.
• Ring can be removed for a short time ( less than 3 hours ) and
can be cleaned and replaced.
Contra- indications of CHCs :
 If female’s age is more than 35
 If she’s a smoker and more than 30 years of age.
 If she’s hypertensive ( BP stays more than 160/100 mm of Hg
)
 Avoid CHCs if she has any present or past history of DVT,
Myocardial infarction or stroke or any other vascular
pathology.
 Avoid CHCs if the patient has multiple risk factors for any
CVS disease such as hyperlipidemia , smoking, diabetes,
weight gain etc.
 Avoid CHCs if she has breast cancer.
 Avoid if she has any thrombogenic mutation that
predisposes her to thrombosis.
Safety profile of CHCs :
 CHCs provide safety against colorectal cancer , ovarian and
endometrial cancer.
 They can however increase risk of cervical and breast cancer.
 Risk of venous thromboembolism also increases with CHC
usage especially in those with previous history of stroke,
migraine ,MI , smoking.
Non- hormonal benefits of CHCs :
 Reduce risk of colorectal, ovarian and endometrial cancer.
 Can be given to people with heavy menstrual bleeding
because estrogen and progestogen levels in CHCs are not that
high so endometrial hypertrophy and glandular proliferation
is reduced resulting in less menstrual bleeding.
 Pills can be given to those with irregular cycles to regulate the
cycles.
 Can be given to females with a lot of androgenic factors such
as hirsutism, acne and other increased testosterone related
features.
 CHC pills can be given to control symptoms of pre- menstrual
syndrome ( fatigue , irritability, mood swings , depression)
2. Progestogen -only contraceptive
(POCs)methods:
They are available in forms of oral pills , injectable, implants and
intra uterine system.
Mechanism of action of POCs :
 They inhibit pituitary gland by negative feedback mechanism
 As a result FSH and LH aren’t produced so ovulation and
consequently fertilization doesn’t occur.
 Different generations of POCs have variable amounts of
progestogens.
 All progestogen only contraceptive methods regardless of route
of administration thicken the cervical mucous and reduce sperm
penetrability and transport.
 At high doses POC formulations also have the ability to atop
ovulation in addition to causing thickening of cervical mucous
 At low doses , ovulation doesn’t stop only mucous is thickened.
 The levonorgestrel intrauterine system has little effect on
.
ovulation but causes marked endometrial atrophy to stop
implantation even if the fertilization occurs.
Types of POC methods :
1.Progestogen-only pills :
 They’re taken continuously orally and on a daily basis ;
there’s no pill-free gap .
 Patient remains in continuous state of amenorrhea
 But patient may experience irregular bleeding in between
because these pills don’t contain a very high level of
progestogens due to which it’s levels can decrease in the
blood resulting in bleeding.
 There’s 2 types of pills ;
Medium dose :inhibit ovulation in 99% cycles + thicken
cervical mucus
Lower dose pills : only thicken the cervical mucus
 If due to some reason the pill is missed , then then the women
should continue taking it when she remembers and use extra
precautions ( e.g. condoms ) for the next 48 hours until the
progestogen effect on mucous is built up.
 Use emergency contraception in case of unprotected intercourse
during this time period
 Side effects of POC pills : irregular bleeding, acne, persistent
ovarian follicles ( simple cysts ).
2. Implants:
 A single rod ( Nexplanon) containing etonorgesteral ( progestogen)
is commonly used .
 Nexplanon is a flexible rod ; the size of a matchstick and is inserted
sub – dermally above medial epicondyle of the arm.
 Insertion is done under local anesthesia using an insertion device
 It provides contraception for 3 years without any follow up needed
 Initial release rate of desogesterol present in nexplanon is 60-70
microgram /day falling to 25-30 microgram/day at the end of 3
years.
 Nexplanon contains a small quantity of bariumwhich permits
it to be visualized by X ray.
 Fertility is restored immediately after removal of the implant
 It is one of the examples of long acting reversible
contraceptives ( LARCS).
3. Progestogen-only injectable :
DMPA and Noristerat ( not used widely ) are available.
Depot medroxyprogesterone acetate :
• Can be administered intramuscularly ( buttocks, upper arm,
lower abdomen) as the formulation Depo-Provera ( 150mg ) or
sub cutaneously as formulation of Sayana press (104mg)
• Users can easily self administer
• Improves symptoms of PMS
• Treats heavy or painful periods
• Useful for women who have difficulty taking pills regularly
 Injectables have a longer duration of action as compared to
pills which is why they can delay return of fertility after
discontinuation for up to 1 year.
 Injection needs to be given every 12-14 weeks.
Side effects of injectables :
 Low estrogen levels and loss of bone mineral density ,
increased risk of osteoporosis
 Delayed return of fertility
 Weight gain
 Bleeding problems e.g. amenorrhea
4. Progestogen releasing intrauterine system:
• Classified as a LARC
• Lasts for 3-10 years depending on type and women’s age
• Releases the progestogen “ levonorgesterol” into the uterus.
• Also known as “ Levonorgesterol intra uterine system”
• Exerts potent hormonal effect on endometrium and prevents
endometrial proliferation and implantation in case the
fertilization occurs
• Also causes thickening of cervical mucous and prevents
entry of sperm
• In first few months of usage many women experience
unpredictable bleeding which improves with time
Beneficial effects of LNG-IUS:
 More effective at reducing heavy menstrual bleeding than
other oral treatments like COCP, tranexamic acid
 Can be used to decrease pain and dysmenorrhea and
bleeding associated with adenomyosis and endometriosis
 Reduces endometrial hyperplasia and risk of endometrial
cancer
Side effects of LNG- IUS :
Acne , mood disturbances, headache, breast tenderness
Contra indications of POCs :
 Pregnancy
 Uterine congenital anomalies or fibroids
 Pelvic inflammatory disease
 Ectopic pregnancy
 Active liver disease
 Hypersensitivity to POCs
3. Barrier methods :
They play a role in preventing entry of sperm into female
genital tract.
Mechanical methods :
 Male and female condoms
 Diaphragms and cervical caps
 Vaginal sponge
Chemical methods :
• Combined hormonal contraception
• Spermicidal agents
Male condom:
• Made from fine latex rubber
• Cheap and widely available
• Protects against STIs and HIV
• Failure rate is 24% and relies on individual to use it correctly
Female condom;
Is a lubricated polyurethane condom inserted into vagina
Protects against STIs
Diaphragm:
Thin latex rubber or silicone hemisphere
Diaphragm should lie across cervix extending from posterior
vaginal fornix to behind the symphysis pubis.
Cervical cap:
• These are Dumas, vimule and Prentif caps made from latex .
The Fem cap is made from silicone
• It fits into cervix by suction
Caps and diaphragms are usually used in conjunction with
spermicides
UTIs are common in diaphragm and cap users.+ Inflammatory
reactions, abrasions or even frank ulcers can be caused by local
pressure.
Vaginal sponges:
 Made of polyurethane foam and impregnated with
spermicide.
 It is inserted in vagina to cover the cervix
 Acts as a carrier for spermicide and absorbs the semen
 “Today “ and “ Protectaid” vaginal sponges are currently
being used.
Spermicides:
• Nonoxynol N-9 is a spermicidal product sold as gel, cream
foam, on sponges etc.
• Used in conjunction with other products
• Can cause vaginal ulceration and irritation and may
increase risk of HIV transmission.
4. Intra-uterine contraception:
 It is the non hormonal method of contraception
 Highly effective for women who want medium to long term
contraception. ( LARC)
 A device is inserted into the uterus that acts as a
contraceptive.
 A fine thread is left protruding from cervix into the vagina
and the IUD can be removed in due course by traction on
thread.
Two types of IUDs can be used : Copper –IUD and LNG-IUS.
Copper intrauterine device:
 Available in various shapes and sizes
 The more copper a device has , the more toxic it is
 The modern banded copper device has copper on the stem and
copper sleeves on the arms
 Failure rate is very less and after insertion female has to check for
the thread regularly 1 time per day which should be present in
vagina provided that the Cu –IUD is at its right location
Mechanism of action of Cu-IUD:
 Copper is toxic to both sperms and eggs as well as the
endometrium but doesn’t cause atrophy
 If sperm reaches the egg and fertilization occurs ; copper
manipulates the endometrium in such a way that implantation
doesn’t occur
 This is why it can also be used as an EMERGENCY
CONTRACEPTIVE if inserted up to 5 days after unprotected
intercourse or 5 days after predicted ovulation.
Cu-IUD has no effect on ovulation and doesn’t cause any
hormonal changes so menstruation keeps on occurring
normally.
Menstruation associated with Cu-IUD :
 Bleeding is very heavy and associated with pain
( dysmenorrhea)
 Tranaxemic acid can be given for heavy bleeding bcoz it
reduces vascular dilation
 NSAIDS can be given for pain relief.
This is why LNG-IUS is preferred over Cu-IUD bcoz it’s a
hormonal contraceptive and bleeding pattern with it is very
light + LNG-IUS also causes endometrial atrophy due to
which endometrial vessels don’t become very tortuous or
dilated.
If while being on Cu-IUD pregnancy occurs there’s a high risk
of it being ectopic in which case it is to be terminated
immediately.
Problems regarding insertion of Cu-IUD :
1.Perforation:
• Female presents with severe pain
• Can occur if IUD was inserted within 6 months of delivery or
due to inexperience of clinician
• If the IUD perforates uterus and enters peritoneum then it can
cause peritonitis ( pain , fever, tenderness of abdomen)
• Perform X ray to find out where the IUD has perforated to
and then remove it immediately.
2.Expulsion:
Risk is more during first 3 months and then gradually decreases
3.Infection:
• Risk is more during first 3 months.
• Vaginal swabs are taken and if Actinomyces like organisms
are seen microscopically but patient is asymptomatic then
you can give her penicillin prophylactically.
• If she is symptomatic with pain, fever abnormal vaginal
discharge then check for location of IUD via X ray….. Take
high vaginal and endocervical swabs for investigations and
screen her for STIs .
4. Missing threads:
• May be bcoz of expulsion of thread with menstruation
• Or incidental expulsion
• Or it could be that the IUD perforated the uterus and moved
elsewhere
• Or the thread might have ascended upwards into cavity of
cervix or uterus.
• If pregnancy occurred ( rare) , then size of uterus increases due
to which thread might have moved upward.
• If you can’t find the thread ; recommend immediate pelvic and
abdominal x ray….. Remove immediately in case of perforation
or pregnancy…. Put the female on emergency contraception in
case of expulsion.
Permanent contraceptive methods:
This involve sterilization of male or female.
Consent is an essential part of it and patient needs to be told
that it’s a permanent method but occasionally it can fail.
Female sterilization:
It involves mechanical blockage of both fallopian tubes to
prevent sperm from reaching oocyte and fertilizing it
Can be done by 3 ways:
 Laparoscopy
 Hysteroscopy
 Laparotomy (e.g. at C section)
Most sterilization is performed by laparoscopy under local
anesthesia
Alternatively, mini laparotomy with small transverse supra-
pubic incision can be done too. Mostly done post-natally.
  During laparoscopy “ Filshie clips” are inserted that block
.

the fallopian tube pathway completely …. When clips are

applied blood supply to that part is due to vessels
compression and the area under the clips is permanently
destroyed.
 Essure is a newer technique involving insertion of metal
springs into each fallopian tube guided by hysteroscope
 In essure, scar tissues grow around the metal springs and
blocks the tube.
 Fallopian rings can also be applied on the tube to
permanently close it off as they promote fibrosis of the tube
after application
 Chemical agents e.g. quinacerine can be inserted via
hysteroscope under local anesthesia; this agent is toxic to
both sperms and eggs and destroys their motility
Complications :
 Anesthetic problems
 Damage to intra- abdominal organs
 Sometimes due to adhesions or obesity, its difficult to
visualize pelvic organs so we proceed to mini laparotomy.
 Ectopic pregnancy
Male sterilization:
Vasectomy:
 Involves division of vas deferens on each side to prevent
release of sperm during ejaculation.
 Done under local anesthesia
 Sperms will still be present higher in the genital tract, and
azospermia is achieved more quickly if there’s frequent
ejaculation
 2 samples of semen at 12 and 16 weeks are taken, if they’re
free of sperm then vasectomy is said to be complete
 Techniques of vasectomy
.

 Ligation or applying clips to vast deferens ( most

common)
 Excision : allows histological confirmation
 Non scalpel vasectomy : inscision isn’t made , special
instruments are used to puncture the skin
 silicone plugs/ sclerosing agents can be inserted into vas
deferens : area slowly becomes fibrosed leading to
sterilization.
 Complications :
o Bleeding, wound infection and hematoma
o Sperm granulomas formation which needs to be
surgically excised
o Chronic scrotal pain at 12 weeks post vasectomy
o Risk of prostate and testicular cancers
Post operative advice :
 The patient may be discharged after 4hrs of procedure,
when the vitals are normal, she’s fully awake and has
passed urine.
 Analgesics , antibiotics should be given accordingly
 1st follow up is within 48 hrs and 2nd is on 7th post-op day to
remove stitches and do pelvic examination
 3rd follow up is a month later or after patient’s first
menstrual period
 Incase of complaints like pain, swelling , fever etc patient
must visit the doctor