Contraception Methods

Introduction to Contraception

• Presented by Dr. Chaambwa H, Obstetrician and Gynaecologist in September 2017.
• Contraception prevents conception through methods other than abstinence.
• Used to manage family size or space births, which is also known as birth control or family planning.

Ideal Contraception Characteristics

• Should be highly effective
• Should be free from unwanted side effects
• Should be absolutely safe for the user
• Independent of the act of intercourse
• Simple to use correctly
• Should be reversible
• Well tolerated by most users

Barrier Methods

• Condoms (male and female) are some of the most widely used methods
• Diaphragms and cervical caps require use with spermicide
• Sponges can be left in the vagina for 24 hours and come in one size fits all options
• Failure rate with the use of spermicides alone is 10-15%

Hormonal Methods

• Combined methods include oral contraceptive pills, hormonal patches, and vaginal rings
• Progestogen-only options are pills, injectable contraceptives, and subdermal implants.

Intrauterine Contraception

• Includes copper intrauterine devices (IUCDs)
• Includes hormone releasing intrauterine systems

Sterilization

• Includes vasectomy for males
• Includes female sterilization.

Natural Family Planning

• Coitus interruptus
• Fertility awareness methods including:
  • Billings (cervical mucus)
  • Basal body temperature
  • Calendar tracking
• Lactational amenorrhoea

Efficacy of Contraceptive Methods

• Virtually all methods can occasionally fail
• Some methods are more effective than others
• The Pearl index (failure rate) expresses the number of failures per 100 women-years (HWY).
• HWY measures the number of pregnancies if 100 women used a method for 1 year.

Contraceptive Method Failure Rates

• Combined oral contraceptive pill has a failure rate of 0.1 with perfect use and 3 with typical use per 100 women per year
• Progestogen-only pill has a failure rate of 1.1 with perfect use and 9.6 with typical use per 100 women per year
• Depo-Provera has a failure rate of 0.1 with perfect use and 2 with typical use per 100 women per year
• Implant has a failure rate of 0.05 with perfect use and 0.05 with typical use per 100 women per year
• Copper-bearing IUD has a failure rate of 0.8 with perfect use and 3 with typical use per 100 women per year
• Levonorgestrel-releasing IUD has a failure rate of 0.5 with perfect use and 0.5 with typical use per 100 women per year
• Male condom has a failure rate of 2-5 with perfect use and 15 with typical use per 100 women per year
• Female diaphragm has a failure rate of 5 with perfect use and 16 with typical use per 100 women per year
• Female condom has a failure rate of 21 with perfect use and 21 with typical use per 100 women per year
• Natural family planning has a failure rate of 2-3 with perfect use and 28 with typical use per 100 women per year
• Vasectomy has a failure rate of 0.02 with perfect use and 0.15 with typical use per 100 women per year
• Female sterilization has a failure rate of 0.13 with perfect use and 0.5 with typical use per 100 women per year
• LAM has a failure rate of 2 with perfect use per 100 women per year
• No method has a failure rate of 85 with perfect use per 100 women per year

Condoms

• Simple to use with a success rate of 85-98%
• Available without side effects
• Help reduce STI, HIV, and cervical neoplasia risks.

Diaphragms and Cervical Caps

• Diaphragms and cervical caps should be used with spermicide.
• Failure rate for diaphragms and cervical caps is 5-16%.
• A sponge can be left for 24 hours and comes in a one size fits all option

Spermicides

• Available in the form of creams, gel aerosols, melting suppositories, and foaming tablets
• Used alone, they have a failure rate of 10-15%.

Oral Contraception

• Two types of oral contraception exist
• Combined Oral Contraceptive Pill
  • A combination of estrogen and progestogen
  • Some common examples are Microgynon, Safeplan, and oralconF
• Progestogen only pill (mini pill)
  • Some common examples are Microlut

Combined Oral Contraceptives (COCs)

• Contain both oestrogen (E) and progestin (P)
• Monophasic pills have the same dose of E/P throughout the course.
• Biphasic pills have a fixed dose of E/P with more P in the last 14/7 days.
• Triphasic pills have a variable dose of E/P.
• Sequential pills have a fixed dose of E, no P for the first 7/7 days, then P for 14/7 days; these are not in common use.

Mechanism of Action of Combined Oral Contraceptives

• Suppress ovulation by inhibiting gonadotrophin secretion via effects on pituitary and hypothalamic centres
• Progestin reduces LH secretion, preventing ovulation.
• The oestrogenic agent suppresses FSH secretion, preventing the selection and emergence of a dominant follicle.

Efficacy of COC

• Typical usage is associated with a 3.0% failure rate during the first year of use.
• Efficacy is significantly decreased when the oestrogen component is removed.

Absolute Contraindications to COC use

• Thrombophlebitis, thromboembolic disorders, CVA, or coronary occlusion
• Markedly impaired liver function
• Known or suspected breast cancer
• Undiagnosed abnormal vaginal bleeding
• Known or suspected pregnancy
• Smokers over the age of 35

Relative Contraindications to COC use

• Migraine headaches
• Hypertension
• History of gestational diabetes
• Elective surgery
• Epilepsy
• History of obstructive jaundice in pregnancy
• Sickle cell disease or sickle C disease
• Diabetes mellitus
• Gall bladder disease

Clinical Problems Associated with COCs

• Breakthrough bleeding
• Amenorrhoea
• Weight gain
• Acne (rare).

Drug Interactions with COCs

• Enzyme-inducing drugs (e.g., barbiturates, antiepileptic drugs except sodium valproate and clonazepam, rifampicin, ketoconazole, griseofulvin, ritonavir, nevirapine) can affect COC efficacy
• Broad-spectrum antibiotics (amoxicillin, tetracycline, doxycycline) can impair ethinyl estradiol absorption
• High-dose preparations (50 µg+ ethinyl estradiol) or barrier methods may be needed when enzyme-inducing drugs or broad-spectrum antibiotics are being taken

Effect of COCs on Other Drugs

• Decreased effectiveness of aspirin, oral anticoagulants, and oral hypoglycaemics
• Increased levels of beta blockers, corticosteroids, diazepam, and aminophylline

Non-Contraceptive Benefits of COCs

• Incidental benefits when COCs are used for contraception
• Benefits for treating problems or disorders

Non-Contraceptive Incidental Benefits of OCs

• Less endometrial cancer
• Less ovarian cancer
• Fewer ectopic pregnancies
• More regular menses
• Less anaemia
• Less PID
• Less rheumatoid arthritis
• Increased bone density
• Less endometriosis
• Less benign breast disease
• Fewer ovarian cysts

COCs as Treatment

• For dysfunctional uterine bleeding (DUB)
• Dysmenorrhoea
• Mittelschmerz
• Endometriosis prophylaxis
• Acne and hirsutism
• Hormone therapy for hypothalamic amenorrhoea
• Control of bleeding
• Premenstrual syndrome

Pill Taking Instructions

• Effective contraception occurs in the first cycle if starting no later than the 5th day of the cycle and pills are not missed.
• If 1 or 2 pills are missed, take the most recent missed pill as soon as possible and continue taking the remaining pills daily at the same time, with no back-up needed.
• If 3 or more pills are missed at any time, take the most recent missed pill as soon as she remembers and continue taking pills daily at the same time, with back-up needed for the next 7 days.

Managing Missed Pills

• If 3 or more pills are missed in the first week and sex has occurred, consider emergency contraception.
• If pills are missed in the 3rd week, finish the current pack, then start a new pack the next day, skipping the pill-free interval.

Combined Oral Contraceptives Advantages

• Simple to use and highly effective
• No special preparation is needed before intercourse
• Relieve irregular menses, cramps, and premenstrual tension

Progestin-Only Pill (POP)

• Contains a low dose of progestogen (25% of that in COC).
• Must be taken daily without interruption.

Mechanism of Action of POP

• Contraceptive effect depends on endometrial and cervical mucus effects, not consistent gonadotrophin suppression.
• The endometrium involutes, hostile to implantation.
• Cervical mucus becomes thick and impermeable.

POP Information

• No significant effects on lipid levels, CHO metabolism, or coagulation factors.
• Immediate fertility returns upon discontinuation.
• Failure rates range from 1.1 to 9.6% per 100 women in the first year.

POP Pill-Taking Instructions

• Start on the first day of menses and use a back-up method for the first 7 days.
• Take the pill at the same time every day.
• If >3 hours late taking a pill, use a back-up method for 48 hours.

Problems Associated with POP

• Unpredictable effect on ovulation
  • 40% can expect normal cycles
  • 40% have short, irregular cycles
  • 20% have a total lack of cycles with irregular bleeding or spotting and amenorrhoea
• Potential development of functional cysts
• Levonorgestrel minipill may cause acne

When POP is Highly Effective

• In lactating women, combined with prolactin-induced suppression of ovulation.
• In women over age 40, reduced fecundity adds to its effects.

Implant Contraception (NORPLANT)

• Progestin circulates at 1/4 to 1/10th the levels of COC, prevents conception by suppressing ovulation and thickening cervical mucus to prevent sperm
• Side effects include changes in menses, weight gain, headache, and mood effects.

NORPLANT Details

• Consists of 6 capsules, each 34mm long, with a 2.4mm outer diameter, containing 36 mm of crystalline levonorgestrel
• The 6 capsules contain a total of 216 mg of levonorgestrel and have an effective life of 5 years
• Capsules release ~ 80 mcg levonorgestrel/24 hours for the first 6-12 months.

NORPLANT Mechanism

• Suppresses both hypothalamic and pituitary LH surge for ovulation.
• Constant progestin levels affect cervical mucus.
• Suppresses estradiol-induced cyclic maturation of the endometrium, causing atrophy.

NORPLANT Disadvantages

• Disrupts bleeding patterns in up to 80% of users.
• Implants must be inserted and removed in a surgical procedure by trained personnel.
• Implants may be visible under the skin.
• Does not protect against STIs/HIV.
• Can lead to acne

Absolute Contraindications for NORPLANT

• Active thrombophlebitis or thromboembolic events.
• Benign or malignant liver tumours
• Known or suspected breast cancer
• Undiagnosed genital bleeding.
• Acute liver disease.

IMPLANON

• Single 4 cm implant which contains 60 mg of 3-keto desogestrel
• The hormone is released at about 60 mcg per day
• Designed to provide contraception for 2-3 years
• Efficacy and side effects are similar to those of NORPLANT.

Jadelle

• Two rods that contains 75mg LNG crystals embedded in a coplolymer and encased in silastic tubing
• Each rod is 43mm long and 2.5mm wide
• Lasts for 5 years
• Easier and more convenient to insert and remove than Norplant
• Bioequivalent to Norplant over 5 years from insertion time.

Injectable Contraception: Depo-Provera

• Microcrystals are suspended in an aqueous solution.
• The correct dose is 150 mg depot medroxyprogesterone acetate IM (gluteal or deltoid) every 3 months.
• Relies on higher progestin peaks to inhibit ovulation and thicken cervical mucus, which then blocks the LH surge.

Depo-Provera Administration Details

• Inject within the first 5 days of the menstruation cycle, otherwise requires a back-up method for 2 weeks
• Inject deeply into muscle using the Z-track technique, without massaging.

Depo-Provera Advantages

• Easy to use, no daily or coital action is needed
• Safe; No serious health effects
• The same effective as sterilization, IUCD & implant contraception
• Free from oestrogen-related problems
• Private method
• Enhances lactation
• Has non-contraceptive benefits

Depo-Provera Disadvantages

• Irregular periods
• The breasts can become tender
• Gain Weight
• Depression is possible
• This isn’t removable
• Delayed in return of fertility
• Needs regular injections to maintain
• No STI/HIV protection

Depo-Provera Contraindications

• Known or suspected pregnancy
• Unexplained genital bleeding

Injectable Contraception: Noristerat

• Consists of Norethisterone enanthate 200mg.
• Provided every 2 months.
• Similar to Depot Provera

Intrauterine Contraception - IUDs

• Two Types (Copper bearing and Hormone Releasing)
• Copper IUDs are known as TCu-380A
• Hormone Releasing IUDs are known as LNG-IUS - mirena.

IUCD Mechanism of Action

• Releases Spermicide into the intrauterine environment, this then interferes with implantation
• Ovulation is not affected during the process, therefore considered non-abortifacient
• Abortifacient means “causing abortion"

IUCD Efficacy

• 3% failure rate during the first year
• The IUD can be expelled 10% of the time
• 15% rate of removal due to bleeding and pain
• Non medicated IUDs never have to be replaced

IUCD Insertion

• Can be inserted during or after pregnancy
• Can be safely inserted any time that includes during a menstrual cycle.
• Can be inserted at Caesarean section when delivering.
• IUCD should not be inserted under defined circumstances

IUCD Use Contraindications

• Can not be inserted if there is a pelvic infection current or within 3 months prior
• Undiagnosed genital tract bleeding present
• Suspected pregnancy
• If the shape of the uterine is distorted - this includes distortions due to fibroids or congenital uterine-malformation cases.
• Past history of ectopic pregnancy presents
• Trophoblastic disease found
• Do not insert a CuT380A with Wilson disease cases, or with one who has a Copper allergy.

Pregnancy and IUDs

• If pregnant, 40-50% will experience Spontaneous abortion
• 10 weeks is the maximum gestational period
• The IUD string must be showing and pregnancy diagnosed with the string present
• If IUD presents pregnancy risks increase four fold, this includes an increase in pre-term labor and birth
• If IUD is left with undetectable string removal procedure may result in a trigger of abortion
• If pregnancy is 12 weeks + then abortion/removal process may trigger an abortion

Missing IUD Strings

• String may be present on the cervical oS area and may have curled up inside
• Device may have expelled itself, patient was not around during expulsion
• Ultrasound and sonography can detect the IUD either within the uterine cavity or if it left the uterine cavity
• String may have torn after insertion due to movement or the device had aged
• String may appear to be short during a regular pregnancy as the growing uterus shifts with fetus.

Natural Family Planning Method

• Requires awareness of fertility
• Involves coitus interruptus
• Fertility awareness is required
  • Requires awareness of mucus around the cervix known as cervical mucus.
  • Temperature awareness by tracking body temperature
  • Use of a calendar method for tracking cycles

Coitus interruptus method

• Removes the penis before ejaculation occurs
• Some sperm may be released before ejaculation
• 1st year failure rate is around 18%
• Better than using no protection at all

Fertility awareness

• Uses naturally occurring indicators and symptoms to determine fertile phases of mensural cycle periods
• Takes life spam of the ovum under accounts in addition to sperm vialblity for planning an effective awareness period

Methods of Fertility Awareness

• Methods of counting calendar and method tracking to manage awareness of fertility
  • Relative and Infertility can be accounted for in a calendar method approach
• Cervical Mucus checks
  • During the fertile period, the cervical mucus is copious
  • During the absolute infertile period there is no known cervical mucus
• Basal body temperature
  • 0.5 temp rise over 3 days signifies end of infertility

Lactational Amennorhoea Method (LAM)

• High concentrations of work at both at anovulation and prolactin to produce lactational amenorrhoea to prevent ovulation
• Proclatin inhibits GNRH

LAM Factors and Protections

• 6 Months is the period of protection
• Only amenorrhoeic women are accounted for only in exclusive breastfeeding at consistent intervals to maintain LAM level protection
  • LAM protection is is the same protection provided from Oral Based Contraception

LAM Facts

• Increase of menstruation or 6 months after birth the rate of ovulation increases
• Supplemental feeding increases the rate of ovulation

Keynote: B/feeding and Contraception

• Be aware of 3's rule In the case of B/ full feeding - use a contraction in the 3rd month In the case of Full and no Full mix , or the lack of b/ feeding begin to take protective measurements around the 3rd week following Progestone usage is OK when b/ feeding

Sterilization

• There is female sterilization for highly successful protection
• There is male sterilization for highly successful protection
• To proceed patients must be satisfied parities or have a precluding pregnancy

Female Sterilization

• This involves removing the fallopian tubes using Laparoscopy, laparotomy, mini-lap
• The times are accounted for using:
  • Caesarean Section
  • Puerperal -Interval

Male Sterilization

• During the procedure Vas Deferens prevent the release of sperm during stimulation
• Is far quicker as a process
• Results can sometimes be delayed of 3- 4months
• Back up protective measures must be maintained before Azosppermia is known

Emeregncy Contraception

• Use following failure or improper usage this helps to prevent pregnancy
• Helps to lesson unplanned pregnancies result in unsafer abortions
• 72 hour period in unprotected intercourse cases, for IUCD it will take effect 5 days aft unprotected inter course

Emergency Contraception Pill Method Types

Progestin option Intra Unit uterine methods Oral Options in pill form

Progestin Contraception Details

Single high dossages of 1500 Mcg of Levonogestreal 750 Mcg of Levonogestreal to be taken over 12 hrs period.

• Brand Names - Ovrette - 20 tablets per dose at 0.0375 mg Levonorgestrel per dose
• Other Brand Names include Microlut, Microval, Norgestron - 25 tablets per dose as 0.03mg Levonorgestrel.

Other Forms of Contraception- IUCD

• Copper T is an IUCD protective measures
• Insertion must take place in 5 days
  • Other protective measures to be known are oral contraceptive pills

Oral Protection

• Use safe ingredients that match standard
• Maintain period of intake over 3 days is recommended after unprotected inter course
• Take tablet every 12 hours

For great success with Emergency Contraceptives note:

Two doses of the COC, at least 1000 MCG EE Pills to take - PC-4, Eugoynon 50, Neogynon, Noral, Nordiol, Ovidon, Ovral, Ovran Each has tablet over 50mg EE and. 0.25mg OR .50 leeonorgestrel. Doses to take: Low Femenal, Microgynon 30, Nordette, Ovral L, Rigevidon and their tables with 30wg EE and a .15 mg are 30 MG

Conclusion

The conclusion is that 6 billion in the world are at risk with 400 million practicing family method techniques.