Contraception

Dr. Mulugeta Desta

June 2023
 Contraception

• All measures designed to prevent pregnancy due to coital act.

• Counselling : informed choice to particular method

• Effectiveness of contraceptive is measured by pearl index:

“ failure rate per hundred woman-years of exposure(HWY)”

PI=
 Contraception

• Top- tier ( Most effective)

• Progestin implants
• Male vasectomy
• Female sterilization( tubal ligation)
• Intrauterine contraception( IUDs)
• Second-tier (very effective)
• Injectable Progestins
• Oral contraceptive pills
• Combined
• Progestin only pills
• Patches
• Vaginal rings
• Third-tier (effective)
• Barriers
• Natural family planning
 Contraception methods
Traditional Barrier Hormonal IUD Sterilization
methods
Coitus interrupts Condom, (male oral, Non- medicated Female ( bilateral
& female) tubal ligation
Post coital douche Diaphragm, injectable, Hormonally Male
medicated ( vasectomy)
Lactational Cervical cap, implants
amenorrhea
Periodic abstinence Vaginal sponge Patches
( rhythm or natural
family planning)
Spermicides Vaginal ring
 Contraception : Traditional methods
• Have No cost , side effect ,or Medical complication
• High failure method
• Includes :
• Coitus interrupts
• Post coital douche
• Lactational amenorrhea
• Periodic abstinence
• Calendar or rhythm method
• Temperature ( basal body temperature = BBT)
• Billing’s ( cervical mucus, symptoms )
• Combined ( calendar + BBT or symptothermal )
 Barrier
• Prevent the sperm from entering into the vagina and/ or cervix
• Advantageous
• Simple to use , found over the counter ,
• Prevents STI/ HIV ( male and female condoms)
• No systemic side effect / medical complications
• No major contraindications
• Disadvantage
• High failure rate
• Not spontaneous
• May also decrease sensitivity ( condoms)
• Allergic (latex condom)
 Barrier
• Male Condom
• Female Condom
• Diaphragm
• Cervical cap
• Spermicidal
 Hormonal contraceptives

• Pills
• Patches
• Vaginal rings
• Injectable
• Implants
 Combined Hormonal contraceptives
• Ingredients
• Synthetic Estrogen (Ethinyl estradiol or mestranol)
• Synthetic progesterone
• Drospirenone, Cyproterone acetate
• Desogestrel, gestodene
• Levonorgestrel , norethisterone, Norethidrine/ acetate, norgestimate
• Mechanism of action
• Inhibit growth of ovulation
• Change consistency of cervical mucus
• Makes endometrial less receptive to implantation
• Altered tubal mobility of both sperm and ovum
 Combined Hormonal contraceptives
• Advantages
• Effective when taken appropriately
• Reduce risk of certain cancers: endometrial, ovarian, colorectal ca
• Protective effect against follicular cysts and breast cysts
• Reduce risk of ectopic, PID, menstrual disorders, and acne
• Prevention in bone mineral density loss: reduce risk of osteoporosis
• Reduce progression of rheumatoid arthritis
• Treat a variety of disorders: Endometriosis, AUB, amenorrhea,
anovulation, Dysmenorrhea, PMD, etc..
 Combined Hormonal contraceptives
• Disadvantages
• Certain drug interactions
• Antibiotics, anti TB, antifungal
• Anticonvulsant
• Long list of contraindications
• Major medical complications
• Thromboembolism: DVT, PE, CVA
• Myocardial infarction, Hypertension
• Cholelithiaisis , cholecystitis
• Hepatic adenomas
• Increase risk of cervical dysplasia and cancer
• Greater side effects:
• Nausea, dyspepsia headache, weight gain, decrease libido
• Breakthrough bleeding, spotting, amenorrhea
 Combined Hormonal contraceptives
• Contraindication
• Pregnancy or nursing
• Undiagnosed AUB
• Prior history of Thromboembolism/ pulmonary embolism, Coronary
artery disease, complicated cardiac disease
• Woman at increased risk of cardiovascular sequel: Smokers >35 age,
Age over 40 , active SLE, uncontrolled diabetes, or hypertension, Sever
dyslipidemia
• Current or prior History of breast or endometrial cancer
• Abnormal liver function or active liver disease
• Migraines
 Combined Hormonal contraceptives
• Oral contraceptives
• Preparation: Monophasic, Biphasic, Tri-phasic
• Time of starting : any time if there is no pregnancy for sure
• Commencement of protection: Immediate / After 7 days
• Change type of COC pills
• Relatively more progesterone or estrogen
• Different phasic type of COC
 Combined Hormonal contraceptives
• Oral contraceptives
• Precautions:
• Medications and GI diseases
• Use backup methods if not started first day of menses
• COC should be stopped
• Six weeks before and 4 weeks after major elective surgery
• Asthma worsened by taking pills
• Sudden migraine attacks, visual disturbances, chest pain
• Development of diabetes & hypertension
• Follow up
 Combined Hormonal contraceptives
• Transdermal patch
• Small 3 layers adhesive patches
• Content: Norelgestromin and Ethinyl estradiol
• 3 consecutive patches are applied in one cycle
• Application site reaction

• Vaginal ring
• Ethinyl estradiol and etonogestrel
• Worn for 3 weeks per month
• Slight vaginal discomfort
• Sensation of foreign body
• Leucorrhea, vaginitis
• Coital problem
 Progesterone only pill
• Composition
• Levonorgestrel/ Norethisterone/lynestrenol/ ethynodiol diacetate
• Mechanism of action
• Cervical mucus thickening and endometrial atrophy
• Advantages
• Good for those estrogen is contraindicated
• Disadvantages
• Side effects
• Menstrual abnormality , Increase formation of follicular cyst.
• Acne, breast tenderness
• Tight schedule
• Less effective: Failure rate 2-7 %
• If failed, risk of increased ectopic pregnancy
 Progesterone only pill

• Indication
• A short term contraceptive , where estrogen is contraindicated
• Contraindications
• Undiagnosed AUB
• Disease of the liver
• A history of ectopic pregnancy
• If a reliable contraceptive is required
• Precaution
• Pill is taken continuously at the same time every day
• If pill is taken later than 3 hrs.
• Sever diarrhea and vomiting
• Timing of intercourse is important
 Depot medroxyprogesterone acetate ( DMPA)
• Also called Depo-Provera
• Given intramuscularly( IM) , 150mg every 3 months
• Mechanism of action
• Mainly Suppression of ovulation
• Cervical mucus thickening, atrophy of endometrium
• Advantages
• Highly effective, less frequent injection ( 4x in a year)
• Has many non-contraceptive advantage
• Disadvantages
• Side effects
• Menstrual abnormality, may worsen PMS, PMDD, slight weight gain
• Mood changes and depression
• Dyspareunia ( bcs of dry vagina) and Bone demineralization
• Delay in return of menses, regular ovulation and fertility
 Depot medroxyprogesterone acetate ( DMPA)
• Indication
• Highly effective contraceptive
• Not want to take daily oral medication
• Where estrogen is contraindicated
• Contraindications
• Current or past history of thrombosis or thromboembolic disorders
• Liver tumors, Active liver disease
• Poorly controlled diabetes
• Depression , migraine
• History or presence of breast cancer
• If short term contraception is required
 Implants
• White, non biodegradable, rod
• Inserted just under the skin
• Types: implant, Jaddel, Implanon
• Implanon: Single rod of etonogestrel, effective for 3 years
• Mechanism of action
• Ovulation inhibition
• Increased viscosity of cervical mucus
• Alters the endometrium
• Indications
• Those who wants long term but reversible method
• For those estrogen is contraindicated
 Implants
• Contraindications
• Current or past history of thrombosis or thromboembolic disorders
• Liver tumors, Active liver disease
• History or presence of breast cancer
• Advantage
• Reversible & quick return to fertility
• No major systemic effect and rare complications
• Does not interfere with sexual intercourse
• No need for regular check up ( except self check)
• No medication stop it from working
 Implants
• Disadvantage
• Side effects:
• Menstrual irregularities (amenorrhea, spotting, infrequent bleeding, HPMB)
• Mood swings, depression, headache
• skin and hair changes, breast tenderness, weight gain
• Not appropriate for those with hormonal precaution
• Need for trained person for Insertion & removal
• Does not prevent STI/HIV
• Time of insertion
• Any time if there is no pregnancy for sure
• Postpartum , post abortion
• Time of removal
 Intra uterine contraceptive device
• Small often T- shaped device or coil.
• Inserted into the uterine cavity
• Types: Inert, Medicated (hormonal), Copper coated
• Mechanism of action
• Chronic Inflammatory reaction
• Thinning and atrophy of the endometrium
• Indications
• Those who wants long term but reversible method
• Those who has precautions (Hormones )
• Requirements
• Healthy genital tact
• Mutual faithful relationship
 Intra uterine contraceptive device
• Advantage
• Long term, Reversible & quick return to fertility
• No major systemic effect and rare complications
• Does not interfere with sexual intercourse
• No medication stop it from working
• Non- contraceptive advantages many
• No need for regular check up ( except self check)
 Intra uterine contraceptive device
• Disadvantage
• Side effects:
• Abdominal cramping, menstrual abnormality, ↑ normal vaginal discharge
• Sore/tender breasts, headaches, changes to your skin
• Mood changes( hormonal)
• Rare complication: perforation , PID
• Method failure ( extremely rare) could lead to ectopic pregnancy
• Need for trained person for Insertion & removal
• Does not prevent STI/HIV
 Intra uterine contraceptive device
• Contraindications
• Suspected pregnancy, GTD
• Small size ( <6cm) or large size ( >10cm) uterine cavity
• Unhealthy uterus: anomalies, infection, malignancy
• High risk for sexual infection
• Hx of EP, higher risk of EP (tubal surgery)
• Undiagnosed AUB
• Wilson’s disease, allergic to Cu , current breast ca( Mirena)
• Immuno-compromised –Leukemia, AIDS, IV drug users, valvular heart
disease
 Intra uterine contraceptive device
• Time of insertion
• Any time if there is no pregnancy for sure
• Postpartum , post abortion
• Time of removal
• Precaution
• Missed thread:
• Do HCG, if pregnant rule out ectopic
• If not pregnant and IUD in uterine cavity with proper position leave it in situ
• Not in the uterus : do pelvic x- ray
• Perforated through the uterus
• Removal by laparoscopy ( preferable) or laparotomy
• Pregnancy and IUD
• Thread visible: remove it
• If not visible: leave in situ
 Surgical sterilization
• Female: Bilateral tubal ligation
• Male: Vasectomy
• Mechanism of action
• Mechanical blocking
• Indications
• Those who wants permanent irreversible contraceptives
• Contraindication
• Medical conditions that would pose a surgical risk
• Not sure of her desire for future pregnancies
 Surgical sterilization
• Disadvantage:
• Irreversible
• Side effect: Short-term discomfort/pain but Quick recovery
• Need for trained personnel
• Need for set up with suitable OR with back up emergency
• Does not prevent STI/ HIV
• Prevalence of service barriers (cultural, social, demographic and services
provision regulations)
• Post operative : infection, bruising, Bleeding/ hematoma formation
• Potential risk of complications, especially if GA used( Bilateral tubal ligation)
• Not fully effective for 3 months after the procedure( Vasectomy)
 Surgical sterilization
• Advantage
• Permanent, safest, Highly effective
• Simple, can be provided in an outpatient setting
• Cost-effective, ideal for those completed family size
• Does not interferer sexual intercourse
• Time of insertion
• Tubal ligation
• Any time if there is no pregnancy for sure
• Postpartum , post abortion , during cesarean section
• Vasectomy : any time
 Surgical sterilization
• Procedure
• Bilateral tubal ligation
• Access:
• Minilaparatomy or Laparoscopy
• Trans-cervical approach, C/section
• Types Irving
• Filshie clip, Falope ring
• Fimbriectomy, Viennese , Pomeray, Madlener, Uchida, Irving
• Vasectomy
• Access: Incisional or No-scalpel Vasectomy( NSV)
• Methods of ligation: Division and ligation or cautery
 Emergency contraceptive
• Prevent unwanted pregnancy from:
• Unprotected sexual intercourse ( dating or rape)
• Method failure (Condom breakage)
• Missed pill taking
• COC ( YUZPE)
• Mechanism: Ovulation inhibition, corpus luteum disruption
• Ingredients: 50 μg Ethinylestradiol + 250 μg Levonorgestral / 500 μg norgestrel
• Dose: Two tablet (Nordiol or Ovral) in 12 hr. apart
• Timing: with in 72hrs of sexual intercourse
• Side effect: nausea, vomiting ,heart burn
• Effectiveness: 78%
 Emergency contraceptive
• Levonorgestral
• Mechanism: Ovulation inhibition, corpus luteum disruption
• Ingredients: Levonorgestral 0.75mg / 1.5mg
• Dose: 1tab(0.7mg) in 12hr apart, 2tab(0.75mg each) once,
1tab (1.5mg) once
• Timing: with in 72hrs of sexual intercourse
• Side effect: delayed menses, break through
• Effectiveness: failure rate 0.1 to 0.2 % if taken with in 12hr
 Emergency contraceptive
• IUD Cu T380
• Mechanism: Inhibit implantation or Inhibits fertilization
• Timing: with in 120 hrs. of sexual intercourse
• Effectiveness: most effective form of all emergency contraceptive
• Disadvantage: risk of STI
• Advantage : can be extended as long term contraceptive

• Current possible ECs

• Ulipristal acetate ( Ella) :30 mg single dose with in 5 days
• Mifepristone: varies doses( 10,50,100,200mg)