contraception seminar

2. CONTRACEPTION
فاطمة حسين كاظم
علياء عماد احمد
فاطمة احمد كاظم
فاطمة حسن علي

3.  Remember
The total risks of birth control are much
less than the total risks of a pregnancy!!
Why is contraception important?
 It prevents unplanned pregnancies and
can give you the freedom to choose the
right time for parenthood
 protect you from most sexually
transmitted infections (STIs)(as condom)

5. Unplanned pregnancies
 Of the 208 million pregnancies that occurred in 2008, an
estimate of 41 percent were unintended1
 If you are having sex and you don’t use contraception
you have an 85% chance of being pregnant within one
year2
 Nearly half of all young people worldwide (46%) have
had sex with a new partner without using contraception3
 Over one third of young people believe the withdrawal
method is effective when it is highly unreliable3
 Contraception allows you to control your natural
fertility and to prevent unplanned pregnancies

6. Characteristics of ideal contraceptive:
 Safe
 100% effective
 Free of side effects
 Available
 Acceptable to the user and sexual partner
 Free of effects on future pregnancies
 Contraceptive efficacy
 Pearl Index
 Life Table Analysis
 Perfect use
 Typical use

7. What are the different
types of contraception

10. Natural Family planning methods
They include:
Calendar (Rhythm) method
Basal body temperature
Cervical mucous method
Ovulation awareness method
Lactational amenorrhea method
Withdrawal ( Coitus interruption )

11. Mechanical family planning methods
 Male condoms
 Female condoms
 Diaphragms
 Spermicidal
 Intrauterine devices (IUD)
 Sponge

12. MALE CONDOM
• Most common and effective barrier method
when used properly
• Latex and Polyurethane should only be used in
the prevention of pregnancy and spread of
STI’s (including HIV)

13. MALE CONDOM
 Perfect effectiveness rate = 97%
 Typical effectiveness rate = 88%
 Latex and polyurethane condoms are
available
Combining condoms with spermicides
raises effectiveness levels to 99%

14. FEMALE CONDOM
Made as an alternative to male condoms
 Polyurethane
 Physically inserted in the vagina
 Perfect rate = 95%
 Typical rate = 79%
Woman can use female condom if partner
refuses

15. The Female Condom
The female condom is a lubricated polyurethane sheath, similar in appearance to a male condom. It is
inserted into the vagina. The closed end covers the cervix. Like the male condom, it is intended for one-time
use and then discarded.
The sponge is inserted by the woman into the vagina and covers the cervix blocking sperm from entering the
cervix. The sponge also contains a spermicide that kills sperm. It is available without a prescription.

16. SPERMICIDES
 Chemicals kill sperm in the vagina
 Different forms:
-Jelly -Film
-Foam -Suppository
 Some work instantly, others require pre-insertion
 Only 76% effective (used alone), should be used in
combination with another method i.e., condoms

17. DIAPHRAGM

18. Cervical Cap

19. Sponge

20. Hormonal contraception
Combined oestrogen and
progestogen
–Combined pill (COC)
–Evra transdermal patch
–Nuva-Ring vaginal ring

21. Combined mode of action of
estrogen and progestogen
 Prevents ovulation
 Thickens mucous in cervix
 Thins endometrium

22. COMBINED ORAL CONTRACEPTIVE
PILLS
 Oestrogens
 Ethinyloestradiol
 Mestranol
 Progestins are also classified to 1st, 2nd, 3rd,
generation progestins
 2nd  levonorgestril
 3rd desogestril & gestodene
 Newer progestins  desogestril & norgestimate have
little or no androgenic activity

23. Dosage & regimen
 Estrogen  20-35μg/ day
 Used for 3 wks with one wk gap when menstruation
occurs
Formulations
 Monophasic  contains fixed amount of estrogen &
progestin
 Biphasic  a fixed amount of estrogen, while the
progestin increases in the 2nd half of the cycle
 Triphasic  the amount of estrogen may be fixed or
variable, while the amount of progestin increases in 3
equal phases

24. COMBINED ORAL CONTRACEPTIVE PILLS
Efficacy
 COCP is highly effective in preventing pregnancy. However
the user failure rate is 3-8%
 30% of women miss 3 or more pills in the 1st cycle of use
 ↑ body Wt may ↓ the efficacy of the pills ( not proven)
Indication
 Any women seeking a reversible, reliable, coitally-independent
method of contraception, in the absence of
contraindications

25. contraindications
Absolute contraindications
 Circulatory diseases
 Significant hypertention
 Arterial or venous thrombosis
 Ischemic heart disease
 Hx of cerebrovascular accident
 Any significant risk factor of cardiovascular disease
 Migraine headache with focal neurological symptoms
 Current breast cancer(oestrogen dependent neoplasm)
 Acute or Severe liver disease

26. Relative contraindications
 Long-term immobilization
 Generalized Migraine
 Irregular vaginal bleeding
 Less sever risk factor of Cardiovascular disease
(obesity,smoking,D.M)

27. SIDE-EFFECTS OF COMBINED OCP
Minor side-effects commonly occure during the 1st
3 cycles
1. Irregular bleeding (breakthrough bleeding/
spotting)
2. Breast tenderness & nausea
 Improve with time
 Less with lower estrogen dosage
3-Mood changes
 Women report depression
& mood changes

28. RISKS OF COCP
1-Venous thromboembolism
 Effect by elter blood clotting & coagulation factor
in way that induce pro-thrompotic tendency
 VTE 3-4 X higher in users than nonusers
 Risk of VTE is higher during the 1st year of use than
subsequent years
 Incidence of VTE in pregnancy is 13/ 10000 deliveries
2-Arterial disease
Increase risk of Myocardial infarction & thrombotic
stroke(smoking will increase risk)

29. RISKS OF COCP
3-Breast cancer
 A large meta-analysis 1996  significant ↑ risk of breast
ca in women currently taking the COCP( Relative Risk
1.24 ) & in the 1st 10 Y after discontinuing it

30. MYTHS & MISCONCEPTION
 COCP affects future fertility
Fact  fertility restored 1-3 M after stopping the pills
 COCP causes birth defects if a woman becomes
pregnant while taking it
Fact There is no evidence that it causes birth defects
 COCP must be stopped in all women >35 Y
Fact Healthy non-smoking women can continue
taking the pills untill menopause

31. Drug interactions
 Anticonvulsants (phenytoin or carbamazepine)
 women should use 50 μg E estradiole pill
Monitor phenytoin level as COCP may inhibit its
metabolism
 Rifampicin contraceptive filure
 Some Broad-specrum antibiotics alter the intestinal
absorpition Of COC

32. Missed pilles

33. EVRA: Simple administration
schedule
20 mcg ethinyloestradiol and 150 –
mcg norelgestromin per 24 hours
Apply weekly for 3 weeks –
Apply same day-of-the-week –
1 week patch-free –
Sunda
y
Sunda
y
Sunda
y
Sunda
y
Patch # 1 Patch # 2 Patch # 3
28-day cycle
Patch-free
Sunda
y
Start next cycle
28-day cycle
Ref: Evra SmPC

34. Vaginal Ring (NuvaRing)
 95-99% Effective A new ring is inserted into the
vagina each month
 Does not require a "fitting" by a health care
provider, does not require spermicide, can make
periods more regular and less painful, no pill to
take daily, ability to become pregnant returns
quickly when use is stopped.
NuvaRing is a flexible
plastic (ethylene-vinyl
acetate copolymer) ring
that releases a low dose
of a progestin and an
estrogen over 3 weeks.

35. PROGESTIN ONLY HORMONAL
CONTRACEPTION

36. ORAL PROGESTINS
PROGESTIN ONLY PILL / MINIPILLS
 Norethisterone 0.35 mg
 Package contains 28 tab
 Started on the 1st day of the menstrual cycle/ or
any day if pregnancy excluded
 Must be used at the same time every day within 3
hrs
 A back up contraception must be used for 7 days
 Must be used continuously  no pill-free interval

37. PROGESTIN ONLY PILL / MINIPILLS
 Perfect use failure rate  0.5%
 Typical use failure rate  5-10% (It must
be taken the same time every day)
 It can be used immediately postpartum
with no effect on lactation

38. Progesterone Only Pills
Clinical uses
– Breastfeeding
– Contraindication to estrogen containing
pills
– Estrogen related side effects on
combination pill
– Heavy smokers over age 35

39. PROGESTIN ONLY PILL
Mechanism of action

40. PROGESTIN ONLY PILL CONTRAINDICATIONS
Absolute Contraindications
 Pregnancy
 Current breast cancer
Relative Contraindications
 Active viral hepatitis
 Liver tumors

41. PROGESTIN ONLY PILL
Side-effects
 Irregular bleeeding
 spotting –12%  1st month
--3%  18 months
40 % continue to have regular cycles
 Hormonal side-effects
Headache, bloating, acne, breast tenderness

42. POP TROUBLESHOOTING
1-Irregular bleeding
 A common side effect
 Pregnancy, infection & genital pathology
must be ruled out
Rx options
 Non steroidal anti-inflammatory for 10
days
 Switching toCOCP
 Adding a short course of estrogen
 Antiprogestinic agents  mifepristone

43. Missed POP pill/s
Less than 3 hours late?
More than 3 hours late
(27 hours after last pill)
Take the missed pill and
continue as normal
Cerazette?
NO YES
Take missed pill as soon as
possible,
Take rest of packet as
normal
And use extra precautions
for the next 2 days
Less than
12 hours late?
More than
12 hours late?
Take missed pill as
soon as possible and
continue with packet
as normal
Take missed pill as soon as
possible, take the rest of the
packet as normal.
Use extra precautions until
pills taken for 2 consecutive
days

44. INJECTABLE PROGESTIN
DEPOT MEDROXYPROGESTRONE ACETATE
 Introduced in 1967 & used by millions of women
worldwide
 Highly effective with a failure rate < 0.3% / year
Mechanism of action

45. DMPA DOSAGE & ADMINISTERATION
 150 mg IM every 12 Wks
 Started during the 1st 5 days of menses or within
5 days of stopping COCP
 Effective within 24 hrs of injection if given during
the 1st 5 days of the cycles
 If given later than D5 of the cycle  back up
method of contraception must be used for 1 wk

46. Clinical Uses
 Can’t or won’t take daily OC
 Breast feeding
Can start after 6 weeks
 Efficacy: 99.7% ( theoretical and actual)

47. DMPA CONTRAINDICATIONS
Absolute contraindications
 Pregnancy
 Unexplained vaginal bleeding
 Current breast ca
Relative contraindications
 Severe liver cirrhosis
 Active viral hepatitis
 Benign hepatic adenoma

48. DMPA SIDE-EFFECTS
1- Menstrual cycle disturbance
 Irregular bleeding  ↓ in frequency & amount over
time
 Abnormally heavy or prolonged occurred only in 1-2%
 Amennorrhea 55-60% at 12 M
68% at 24 M
2-Hormonal side effects
 Headache 17%
 Acne
 ↓↓ libido
 Nausea
 Breast tenderness

49. DMPA SIDE-EFFECTS
3-Weight gain
 56% ↑↑ Wt ( mean gain 4.1 kg)  possibly through
appetite stimulation & a mild anabolic effect
 44% ↓ Wt or maintained (mean loss 1.7 kg)
4-Mood effects
 Prospective studies did not demonstrate ↑ depressive
symptoms
 Some women discontinue use because of mood
changes

50. DMPA RISKS
1-Delayed return of fertility
 An average of 9 months delay before restoration of
full fertility after last injection
 Rate of conception 50% at 10 M, 90% at 24 M
2-Reduction in bone mineral density
 A mean loss of BMD at the lumbar spine 0.87-3.5%
 Increase risk of osteoporosis
 It improves after discontinuation of use
3-VTE, CVD, Stroke  No ↑ risk

51. PROGESTIN IMPLANTS
 NORPLANT  Levonorgestril
 Implanon  Etonogestrel
 Highly effective failure rate 0.1% / year
 Implanon consist of single silastic rod that are
inserted subdermally under local anaesthetic into
the upper arm
 Women < 70 kg effective for 7 Y pearl index < 2
 Reversible contraception
 Mechanism of action
 Suppression of ovulation
 Endometrial atrophy
 Rendering Cx mucous impermeable to sperms
 Prolonged irregular bleeding the major side effect

52. Implant

53. IUCD
 Copper IUCD( Nova T)
 Homone– releasing IUCD :levonorgestrel
releasing IUD (mirena) .
Efficacy
 Failure rate of Nova T  1.26 % /year
----------------Mirena  0.09 % /year

54. Mechanism of action
INSERTION
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55. Copper _IUCDs
What are their main advantages?
 Effective in general for 10 years
 Do not interrupt sex
 Normal fertility returns as soon as they are removed
What are their main disadvantages?
 May cause heavier, longer or more painful periods,
increased cramping and dizziness
 Do not protect against STIs
 Small risk of expulsion or perforation
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56. Hormonal IUCD
What are its main advantages?
 Effective for up to five years
 Does not interrupt sex
 Option for those who cannot tolerate estrogens and those breast-feeding
 Periods become lighter and shorter, and less painful
 Normal fertility returns quickly when the IUS is removed
 Not affected by other medicines
 Protection against pelvic inflammatory disease
What are their main disadvantages?
 Can cause irregular bleeding, particularly for the first three months
 May cause temporary side-effects such as headaches, breast
tenderness ,acne and nausea
 Small risk of expulsion or perforation
 Functional ovarian cyst
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57. INDICATIONS FOR IUCD
 In the absence of contraindications may be
considered for any woman seeking a reliable,
reversible, independent method of contraception
 Women seeking long term birth control
 A method requiring less compliance
 Women with contraindications to estrogen
 Breast feeding women
 Copper IUCD used for emergency contraception
within 7 days
 LNG- IUCD ↓↓ menstrual flow & cramping suitable
for women with menorrhagia & dysmenorrhea

58. IUCD CONTRAINDICATIONS
Absolute contraindications
 Pregnancy
 Current, recurrent or recent (within 3 M) PID or
sexually transmitted disease
 Puerperal sepsis
 Immediate post septic abortion
 Severely distorted uterine cavity
 Unexplained vaginal bleeding
 Cx or endometrial ca
 Malignant trophoblastic disease
 Copper allergy Copper -IUCD
 Breast ca  LNG -IUCD

59. IUCD CONTRAINDICATIONS
Relative contraindications
 Risk factor for sexually transmitted diseases or
HIV
 Impaired response to infections:
-HIV +ve women
-Women on corticosteroid Rx
 48hrs- 4 wks postpartum
 Ovarian ca
 Benign gestational trophoblastic disease

60. IUCD PROBLEMS
1-Uterine perforation
 A rare complication at insertion
Risk factors
 Postpartum insertion
 Inexperienced operator
 Immobile uterus
 Extremely ante or retro –verted uterus
2-Expulsion
 2-10% in the 1st year of use
 Risk factors: postpartum insertion, nulliparity,previous
expulsion(30% chance)

61. IUCD PROBLEMS
3-Infection
 Risk is ↑↑ only in the 1st few months after insertion
 Inverse relation between infection & time since insertion
4-Failure
 If a woman become pregnant with an IUCD  exclude ectopic
 Abortion is ↑↑ in women pregnant with IUCD in place
 Preterm delivery ↑↑ in women pregnant with IUCD in place

62. FOLLOW UP
A follow up visit must be scheduled in 6 wks then
yearly
Women must be instructed to come if;
 IUCD thread can not be felt
 She feels the lower end of the IUCD
 Pregnant
 Abdominal pain, fever or unusual discharge
 Pain or discomfort during intercourse
 Sudden change in menstrual period
 Wants to remove the device or concieve

63. Emergency Contraception
Is any drug or device used after
intercourse to prevent
pregnancy ,to prevent
implantation of fertilized egg

64. Emergency Contraception
Options
Oral contraceptive pills containing •
only progestin
Oral contraceptive pills containing •
estrogen and progestin
Emergency Copper-T IUD •
insertion

65. Emergency Contraceptive
Pills: Progestin-only
Birth control pills containing only progestin •
2 doses :First dose within 72(120) hours after •
intercourse
Second dose 12 hours later(or maybe not!) •
Or single dose of 1 .5mg of levonorgestrel •
Less nausea/vomiting than combined ECPs •

66. Emergency Copper IUD
Insertion
Copper- IUCD . •
can be inserted up to 7 days after •
intercourse
Much more effective than ECPs •
Not recommended for women at risk of •
sexually transmitted infections (STIs)

67. Emergency Contraceptive
Effectiveness
If 1000 women have unprotected sex once
in the second or third week of their cycle
# of Pregnancies % Reduction
No treatment 80
Combined ECPs 20 75%
Progestin Only
10 88%
ECPs
IUD Insertion 1 99%

68. Sterilisation
What is it?
 Permanent method of contraception for people who do not want
children now or in the future
How does it work?
Male sterilisation (vasectomy)
 The tubes that carry sperm are cut and blocked, so that
while ejaculation can take place, no sperm is present
Female sterilisation
 The Fallopian tubes are cut or blocked so that
the egg cannot meet sperm
68

69. Sterilisation/Vasectomy

70. Sterilisation
What are its main advantages?
 Permanent and highly effective
 Does not interrupt sex
What are its main disadvantages?
 Cannot be reversed (except by using complex and potentially
dangerous surgery which is not successful in all cases)
 Does not protect against STIs
70