Famil Planning

05/30/2024 By Asamere & Ali 1
Combined Hormonal Contraceptives(CHC)

• Hormonal contraceptives are female sex steroids, synthetic estrogen
and synthetic progesterone (progestin), or progestin only.
• They can be administered in the form of OCs, patches, implants, and
injectable.
• The most widely used hormonal contraceptive is the combination OC.

Combined Oral Contraceptives(COC)
• Combination of two hormones: estrogen and progestin
• can be monophasic, with the same dose of estrogen and progestin
administered each day, or multiphasic in which, varying doses of
steroids are given through a 21-day cycle.
• 21/7 triphasic vs 24/4 monophasic
• Extended use of CoC->28 days
• Low-dose: 30-35 μg of estrogen (common), 20 μg or less (rare in most
places)

Mechanism of Action

MOA
• Suppression of hypothalamic GnRH factors in turn block pituitary
release of FSH & LH to inhibit ovulation
• Progestins inhibit ovulation by suppressing LH, they thicken cervical
mucus w/c retard sperm passage, and they render the endometrium
unfavorable for implantation.
• Estrogen suppresses FSH release
• Fortunately, CHCs are not teratogenic if taken accidentally during
early pregnancy (Lammer, 1986).COCs have no effect on an existing
pregnancy

When to start
• Having menstrual cycle
-With in 5 days --- no need of backup*
-Delayed > 5 days ---- backup for the first 7 days of taking pills.
• Switching from an IUD ---start immed. & no backup
• From hormonal method --- if use was consistent & correct or
reasonably certain that she is not pregnant ---start immed. & no backup
• Fully or near fully breast feeding
-Start at 6mo or when supplementation started
- >6mo & no menses--- R/O pregnancy + backup

Partial breast feeding
- <6wk---start at 6wk
->6wk & no menses ---R/O pregnancy + backup
 Non breastfeeding
-<4wks---start anytime b/n 21-28days
->4wk & no menses---R/O pregnancy + backup
After miscarriage
-<7days ---no backup
->7days----backup
 After ECPs----the day ECPs finished + backup
 No monthly bleeding ----R/O pregnancy + backup
Managing missed pill

Known Health Benefits
• Help to protect:
-Risks of pregnancy
-Cancer of ( uterus , ovary ) but relative risk for cervical ca and dysplasia increase
for current user .
• Reduce
-Menstrual cramps
-Menstrual bleeding problems
-Ovulation pain
• Excess hair on face or body
• Symptoms of polycystic ovarian syndrome (irregular bleeding, acne, excess hair on face or
body)
• Symptoms of endometriosis (pelvic pain, irregular bleeding)
Side effects
• Changes in bleeding patterns including:
– Lighter bleeding and fewer days of bleeding
– Irregular bleeding
– Infrequent bleeding
– No monthly bleeding
• Headaches Nausea
• Breast tenderness Dizziness
• Weight change Mood changes
• Other possible physical changes:
• Blood pressure increases a few points (mm Hg). When increase is due to COCs, blood
pressure declines quickly after use of COCs stops.
Non Contraceptive Benefit

WHEN TO WITHDRAW?
• The indications for withdrawal of the pill are—
(1) Severe migraine;
(2) Visual or speech disturbances;
(3) Sudden chest pain;
(4) Unexplained fainting attack

Category 3 conditions for COC
• 6wk-6mo & B/F • Medically treated gall bladder
disease
• Post partum<21days
• Age<35 + migraine without aura(c)
• ≥35yr & smoking<15cig.
• Age≥35 + migraine without aura( I )
• Hx of ↑ed BP where BP can’t be
measured • Hx of breast ca.
• Past COC related cholestasis
• SBP 140-159mmhg
• Acute viral hepatitis
• DBP 90-99 mmhg
• ARV , anticonvulsant or rifampicin
• Well controlled HTN
therapy
• Current gallbladder dis
Category 4 conditions for COC
• <6wk & breast feeding • Current /Hx of ischemic heart
• ≥35 & smoking ≥15 cig. dis./stroke
• SLE with positive antiphospholipids
• CVD + multiple risks
antibody
• SBP≥160mmhg or DBP ≥100mmhg • Age ≥35+ migraine with aura( I )
• ↑ed BP + vascular dis. With out aura (c)
• Acute or Hx of DVT/PE • DM with nephropathy, neuropathy ,
• Known thrombogenic mutation retinopathy
• Complicated VHD • Severe cirrhosis
• Current breast ca. • Hepatocellular ca.
• DM>20yrs • Hepatocellular adenoma
Transdermal System
• available in USA as- Ortho Evra patch.
• has an inner layer with an adhesive and hormone matrix and an outer
water-resistant layer.
• site -buttocks, upper outer arm, lower abdomen, or upper torso but
avoids the breasts
• It delivers daily dose of 150 µg of the progestin norelgestromin and 20
µg of ethinyl estradiol.
• A new patch is applied each week or 3 weeks, followed by a patch- free
week to allow withdrawal bleeding.
• Efficacy -1.2 pregnancies per 100 woman year.
Transvaginal Ring
• available in the United States—NuvaRing.
• It is a flexible polymer ring with a 54-mm outer diameter and a 50-
mm inner diameter
• Its core releases a daily dose of 15 µg ethinyl estradiol and 120 µg of
the progestin etonogestrel.
• Failure rate is reported to be 0.65 pregnancies per 100 woman-year

Transvaginal Ring
• the pharmacy must keep rings refrigerated.
• Once dispensed, their shelf life is 4 months.
• The ring is initially inserted within 5 days after the onset o menses.
• It is removed after 3 weeks or 1 week to allow withdrawal bleeding.
• Drawback- Up to 20 percent o women and 35 percent of men
reported being able to eel the ring during intercourse

Progestin-Only contraceptive
• Pills that contain very low doses of a progestin like the natural hormone
• progesterone in a woman’s body.
• It includes:-
(implants , pop (mini pills) and injectable )
• Option for women in whom an estrogen-containing contraceptive is either
contraindicated or causes additional health concerns.
• Use=suitable for lactating mother
-Smokers>35 yrs
-Hx of thrombosis or migraine headache
-Do not exacerbate or cause HTN
• Side effects= irregular bleeding
-slightly higher preg. rate>CHC
-Functional Ovarian Cyst as disadv.
• Not used in- un explained Ux bleeding
-breast cancer
-pregnancy
-hepatic neoplasms or active severe liver disease

Medical Eligibility Criteria for POPs
• If she develops severe cirrhosis or severe liver tumor, such as liver
cancer), do not provide POPs. Help her choose a method without
hormones.
• If she reports a current blood clot in a leg (affecting deep veins, not
superficial veins) or in a lung, and she is not on anticoagulant therapy,
do not provide POPs.
• If she is taking barbiturates, carbamazepine, oxcarbazepine,
phenytoin, primidone, topiramate, rifampicin, or rifabutin, do not
provide POPs. They can make POPs less effective.

• If she have current or previous hx of breast cancer,do not provide
POPs.
• Also, women should not use POPs if they report having thrombogenic
mutations or lupus with positive (or unknown) antiphospholipid
antibodies.
• Women living with HIV or on antiretroviral therapy can safely use
POPs. Urge these women to use condoms along with POPs.

When to start POPs

• Fully or near fully breast feeding
-<6mo after giving birth & no menses she can start POPs anytime
b/n giving birth* &6mo & no backup
>6mo after giving birth & no menses R/O pregnancy + backup for
the 1st 2 days
• Partial breast feeding
If no menses → she can start POPs anytime after R/O pregnancy
+ backup for the 1st 2 days
* This is new FP recommendation from WHO 2018

• Not breast feeding
<4wk post partum→ start any time + no back up
>4wk post partum→ if no menses R/O pregnancy start backup
• Switching from hormonal method
-Start immediately & no backup if she has been using the
hormonal method consistently and correctly or if it is otherwise
reasonably certain she is not pregnant.

Managing Missed Pills
• If a woman is 3 or more hours late taking a pill (12 or more hours late
taking a POP containing desogestrel 75 mg), or if she misses a pill
completely, she should follow the instructions below.

Injectable Progestins
• Include:- DMPA[Depo-Provera]- A 150-mg dose is given by IM every
90 days.
• A derivative of DMPA is depo-subQprovera 104, and a 104-mg dose is
given subcutaneously every 90 days.
• Norgest, and a 200-mg dose is injected intramuscularly every 2 mo.
• Injectable progestins have contraceptive efficacy equivalent or better
than that of COCs.

• Progestin injectable should not be taken by women with pregnancy, unexplained uterine
bleeding, breast cancer, active or history of thromboembolic disease, cerebrovascular
disease, or significant liver disease (Pfizer, 2014)
• Notable Effects-DMPA usually causes irregular menstrual-type bleeding.
-Amenorrhea [extended use],breast tenderness, wgt gain,
-Prolonged ovulation suppression
- Diminished bone mineral density[long tem use]
because o lowered estrogen levels
• Of potential cancer risks, cervical carcinoma in situ rates are possibly increased with
DMPA use.
• Advantageously, ovarian and endometrial cancers are decreased (Kaunitz, 1996; WHO,
1991)

Medical Eligibility Criteria for
Progestin-Only Injectables
• She can start using progestin-only injectables as soon as 6 weeks after
childbirth
• If she reports severe cirrhosis or severe liver tumor, such as liver
cancer, do not provide progestin-only injectables.
• If she is currently being treated for high blood pressure and it is
adequately controlled, or her blood pressure is below 160/100 mm
Hg, provide progestin-only injectables

• If she reports having high blood pressure in the past, and you cannot
check blood pressure, provide POIs.
• If SBP>= 160 OR DBP>=100mm Hg , do not provide POIs.
• If she reports diabetes for more than 20 years or damage to your
arteries, vision, kidneys, or nervous system caused by diabetes, do
not provide progestin-only injectables
• If she reports heart attack, heart disease due to blocked or narrowed
arteries, or stroke, do not provide progestin-only injectables

• If she has unexplained vaginal bleeding that suggests pregnancy or an
underlying medical condition, POIs could make diagnosis and
monitoring of any treatment more difficult…alternative
• If she have current or previous hx of breast cancer,do not provide
POIs.
• Also, women should not use POPs if they report having thrombogenic
mutations or lupus with positive (or unknown) antiphospholipid
antibodies.
• Women living with HIV or on antiretroviral therapy can safely use
POPs. Urge these women to use condoms along with POPs.
When to Start

• Fully or near fully breastfeeding
< 6mo after birth → delay injection at least until 6wk PP
if has no menses → start anytime b/n 6wk&6mo. + no backup
>6mo after birth → if no menses → R/O pregnancy + backup for
1st 7 days
• Partial breast feeding
<6wk delay until 6wk PP
>6wk & no menses → R/O pregnancy + backup for 1st 7 days

• Non breastfeeding
< 4wk → start anytime + no backup
>4wk & no menses → R/O pregnancy + backup
• No monthly bleeding (not related to child birth or pregnancy → R/O
pregnancy + backup
• After taking ECPs → on the same day or with in 7days after the start
of menses(backup)
• Repeat injection → 2wks early or late

Implanon

Implanon

Implanon
• It is a progestin only delivery system containing 3 Ketodesogestrel
(etonorgestrel).
• It is a long-term (up to 3 years) reversible contraception
• t releases the hormone about 60 mcg, gradually reduced to 30 mcg
per day over 3 years.
• Implanon does not cause decrease in bone mineral density

Types
• Jadelle: 2 rods, lasts 5 years
-75 mg of levonorgestrel
• Implanon: 1 rod, lasts 3 years
-68 mg of etonogestrel
• Sinoplant: 2 rods, each 75 mg of levonorgestrel, lasts 5 years

Implants
• If she reports severe cirrhosis or severe liver tumor, such as liver
cancer, do not provide implants.
• If she reports a current blood clot in legs (affecting deep veins, not
superficial veins) or in a lung and she is not on anticoagulant therapy,
do not provide implants.
underlying medical condition, implants could make diagnosis and
monitoring of any treatment more difficult.

• If she have current or previous hx of breast cancer, do not provide
POIs.
• Women should not use implants if they report having lupus with
positive (or unknown) antiphospholipid antibodies and are not on
immunosuppressive therapy.
• Women who are living with HIV or are on antiretroviral (ARV) therapy
can safely use implants.
• Efavirenz may reduce the effectiveness of implants.
• Urge women taking this ARV to use condoms along with implants to
provide better protection from pregnancy.
Norplant–II (Jadelle):
• Two rods of 4 cm long with diameter of 2.5 mm is used.
• Each rod contains 75 mg of levonorgesterel.
• It releases 50 mcg of levonorgestrel per day.
• Contraceptive efficacy is similar to combined pills.
• Failure rate is 0.06 per 100 women years.
• It is used for 3 years.
• The rods are easier to insert and remove.

Insertion:
• inserted subdermally, in the inner aspect of the non dominant arm,
6–8 cm above the elbow between biceps and triceps muscles.
• Preloaded sterile applicator is available. No incision is required.
• It is ideally inserted within D 5 of a menstrual cycle, immediately after
abortion and 3 weeks after postpartum.

removal:
• done by making a 2 mm incision at the tip of the implant and pushing
the rod until it pops out.
• It is done under local anesthetic.
• Implanon should be removed within 3 years of insertion.
• Loss of contraceptive action is immediate

Advantages
• are the same as with DMPA.

• Others are-
(i) Highly effective for long-term use and rapidly reversible.
(ii) Suited for women who have completed their family but do not
desire permanent sterilization.
• Efficacy of implanon is extremely high with pearl index of 0.01 women
years.
• This safe and effective method is considered as ‘reversible
sterilization’

Drawbacks:-
• Frequent irregular menstrual bleeding, spotting and amenorrhea are
common.
• Difficulty in removal is felt occasionally.
• Contraindications (i) Pregnancy
(ii) unexplained vaginal bleeding
(iii) recent breast cancer
(iv) arterial disease.
(v) thromboembolic disease.

Intra-Uterine Contraceptive
Devices (IUCD)

Intrauterine device (IUD)
• most commonly used method of long-acting reversible contraception
because of its high efficacy and safety, ease of use, and cost
effectiveness.
• It provides a nonsurgical option for pregnancy prevention that is as
effective as surgical sterilization.

Types of IUDs
• Copper containing and levonorgestrel releasing:-
-Copper – bearing: which include the Cu-T 380A, Cu-T 380A with safe
load, Cu-T 200C, Multilaod (MLCu 250 and 375), and the Nova T.
-Medicated: with a steroid hormone, such as the levonorgestrel
containing Mirena IUS(intrauterine system)

MOA of IUD
• Changes in cervical mucus that inhibit sperm transport (eg, increased
copper concentration, thickening, glandular atrophy or
decidualization)
• Chronic inflammatory changes of the endometrium and fallopian
tubes, which have spermicidal effects and inhibit fertilization and
implantation.
• Thinning and glandular atrophy of the endometrium, which inhibits
implantation
• Direct ovicidal effects

Copper -Bearing IUDs
• Delay inserting an IUD until 4 or more weeks after childbirth.
• If she currently has infection of the reproductive organs during the
first 6 weeks after childbirth (puerperal sepsis) or she just had an
abortion-related infection in the uterus (septic abortion), do not
insert the IUD.
underlying medical condition, use of an IUD could make diagnosis and
monitoring of any treatment more difficult.

• Known current cervical, endometrial, or ovarian cancer; gestational
trophoblast disease; pelvic tuberculosis: Do not insert an IUD.
• If a woman has HIV infection with severe or advanced clinical disease,
do not insert an IUD.
• In contrast, a woman living with HIV who has mild clinical disease or
no clinical disease can have an IUD inserted, whether or not she is on
antretroviral therapy.

• Women who have a very high individual likelihood of STI infection
should not have an IUD inserted unless gonorrhea and chlamydia are
ruled out by lab tests.
• Rule out pregnancy before inserting IUD.
• women should not use the IUD if they report having systemic lupus
erythematosus with severe thrombocytopenia.

Advantages and Health Benefits
• Highly effective.
• Safe for most women.
• Reversible and economical.
• May be safely used by lactating and postpartum women.
• Good choice for older women with COC precautions.
• Long duration of use.

• One visit for insertion and minimal follow up required after first 3-6
week checkup (unless the client has problems).
• Because nothing is required during sexual intercourse, IUDs allow
women privacy and control over their fertility.
• Does not interact with medications.
• Can be removed whenever the client chooses

Disadvantages and Health Risks
• Does not protect against STIs/HIV.
• Pelvic Inflammatory Disease (PID) may occur if she has
• Chlamydia or gonorrhea at the time of IUD insertion.
• Infection if IP practices are not followed during insertion .
• Trained provider dependent.
• Some pain, cramping, minor bleeding on insertion

• Heavier/longer menstrual periods, increased cramping, and
bleeding/spotting fairly common in the first 3 months
• Anemia if the IUD causes heavier monthly bleeding.
• Rarely, uterus may be punctured during IUD insertion.
• Require good back up services.
Note: IUDs do not increase the risk of ectopic pregnancy

Efficacy of IUDs
• Is one of the most effective contraceptive methods.
• Efficacy – pregnancy rate < 1% woman years.
• As typically used, 0.8 pregnancies per 100 women

Category -4 conditions
for Cu-T380A IUD use
• Pregnancy
•Puerperal sepsis
• Immediate post septic abortion
• Distorted uterine cavity
• Myoma with uterine cavity distortion
• Persistently elevated B-HCG level(GTD/GTN)

Contraindications to IUD use
• listed by the World Health Organization include pregnancy, puerperal
sepsis, PID or sexually transmitted diseases current or within the past
3 months, endometrial or cervical cancer, undiagnosed genital
bleeding, uterine anomalies, and fibroid tumors that distort the
endometrial cavity.

Permanent Methods of FP
Female sterilization & vasectomy

FEMALE STERILIZATION
• Female sterilization is usually accomplished by occlusion or division of
the fallopian tubes
• Puerperal sterilzn VS NonPuerperal sterilzn (interval sterilzn ).

• The cumulative failure rate for the various tubal procedures was 18.5
per 1000 or approximately 0.5 percent.
• The study found puerperal sterilization to be highly effective.
• The 5-year failure rate was 5 per 1000, and for 12 years, it was 7 per
1000.

• Side Effects- None
• Known Health Benefits: Helps protect against:
-Risks of pregnancy
-Pelvic inflammatory disease (PID)
-May help protect against: Ovarian cancer
• Known Health Risks:
-Uncommon to extremely rare:
- Complications of surgery and anesthesia

• Complications of Surgery (Uncommon to extremely rare)
• Infection or abscess of the wound.
• Death, due to the procedure or anesthesia, is extremely rare.
• The risk of complications with local anesthesia is significantly
lower than with general anesthesia

Procedure used to Access the
Fallopian Tubes
• Minilaparotomy
-3-5cm incision is made in the abdomen
• Laparoscopy
-A laparoscope is inserted into the abdomen through a 1-cm incision
• Cesarean section

Vasectomy

What Is Vasectomy?
• A permanent contraception for men.
• Closing off each vas deferens, keeping sperm out of semen.
• Highly effective (comparable to FS, implants and IUDs)
• Not effective immediately—backup contraception for 3 months after
the procedure
• Failure (pregnancy rate) is 0.2% to 0.4%.
• Doesn’t protect from HIV/AIDS

• Very safe; few restrictions
• Regret :
-Some times in young age, marital instability and decision made
under pressure
-To minimize regret careful counseling is critical.
• Complication is rare, occurs in <1% of NSV
-Pain, infection and bleeding

SHORT
SUMMARY
2016 WHO Medical Eligibility Criteria for
Contraceptive Use

…2016 WHO Medical Eligibility Criteria
 I/C Initiation/Continuation: A woman may fall into either one category
or another, depending on whether she is initiating or continuing to use a
method. Where I/C is not marked, the category is the same for initiation
and continuation.
 NA Not Applicable: Women who are pregnant do not require
contraception. If these methods are accidentally initiated, no harm will
result.
 i The condition, characteristic and/or timing is not applicable for
determining eligibility for the method.
 ii Women who use methods other than IUDs can use them regardless of
HIV/AIDS-related illness or use of ART.
 * Other risk factors for VTE include: previous VTE, thrombophilia,
immobility, transfusion at delivery,BMI > 30 kg/m2, postpartum
hemorrhage, immediately post-caesarean delivery, pre-eclampsia,
and smoking.
 ** Anticonvulsants include: phenytoin, carbamazepine, barbiturates,
primidone, topiramate, oxcarbazepine, and lamotrigine. Lamotrigine
is a category 1 for implants

• This chart shows a complete list of all conditions classified by WHO as
Category 3 and 4.
• Characteristics, conditions, and/or timing that are Category 1 or 2 for
all methods are not included in this chart (e.g., menarche to < 18
years, being nulliparous, obesity, high risk of HIV or HIV-infected, < 48
hours and more than 4 weeks postpartum).

References used

References used
• DC DUTTA’s TEXTBOOK OF OBSTETRICS including Perinatology
Contraception
• Williams Gynecology, Third Edition 3rd Edition 2016 [UnitedVRG]
• Novak's Gynecology_14ed
• 2016 WHO Medical Eligibility Criteria for Contraceptive Use: Quick
Reference Chart for Category 3 and 4
• EDHS 2016

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05/30/2024 By Asamere & Ali 1

Combined Hormonal Contraceptives(CHC)

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• are the same as with DMPA.

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