[HD 201] E03-T04-Family Planning Methods_compressed

• HD 201 covers Human Development 1: Human Ontogeny and Parturition.
• Lectures cover Family Planning Methods.

Introduction

• World population is 8.1 billion.
• During the pandemic, healthcare access was compromised.
• As a result, some patients who didn't want to get pregnant ended up pregnant.

Family Planning

• Family planning (FP) is an unmet need in the Philippines.
• More unmarried women desire family planning than married women.
• In 2017, 5.1 million unmarried women wanted family planning but couldn't access it, compared to 2.6 million married women.
• Unplanned pregnancies are common, therefore, conceptional counseling is advocated.
• Patients should be seen 6 months to a year before pregnancy to optimize their condition.
• Family planning is a choice, not a chance.
• Globally, 225 million women in developing countries lack access to family planning information and services.
• The unmet need for family planning is highest for women in the postpartum period.
• Family planning should be set during the antenatal or prenatal checkup.
• Family planning requires the patients consent and harmony between patient and partner.
• Addressing the unmet need for family planning can avert more than 30% of maternal deaths.
• Family planning improves maternal and infant health.

Benefits of Family Planning

• Supports Partnerships within the family.
• Brings an end to hunger and poverty.
• Increases educational outcomes.
• Saves the environment.
• Empowers women to make informed choices.
• Aids in decreasing HIV/AIDS transmission.
• Improves maternal health.
• Improves infant health.
• It is the reproductive and sexual health right of the patient to make family planning decisions.
• It is a shared decision between a husband and the patient.

Puerperium

• This period is 6-8 weeks after delivery.
• It presents an excellent opportunity to provide effective contraception.
• Discussions should cover desired methods and lifestyle fit.
• Exclusively nursing mothers can use the Lactational Amenorrhea Method (LAM).
• LAM involves exclusive breastfeeding within 6 months as long as the patient is NOT menstruating.
• Ovulation during the first 10 weeks postpartum is unlikely.
• Mixed feeding (bottle and breastfeeding) makes nursing unreliable for family planning.
• Waiting for first menses involves risk due to ovulation antedating menstruation.
• Others extend LAM to 8-10 months, but the method only promises up to 6 months.
• Contraception is essential after the first menses unless pregnancy is desired.
• Advanced maternal age (AMA) is 35 years.
• With AMA, there's a tendency to rush pregnancy.
• Ideally, there should be 3 years between pregnancies.
• Short interpregnancy intervals are associated with risks of low birth weight and preterm delivery.

Contraceptive Methods

• Includes options such as condoms, female condoms, birth control pills, hormonal rings, IUDs, contraceptive injections, surgical sterilization, diaphragms/caps, and patches
• All contraceptive methods have two types of effectiveness.

Method Effectiveness

• Typical Use Effectiveness includes rates given actual use, accounting for occasional, inconsistent, or incorrect use
• Perfect Use Effectiveness are the rates if the method is used correctly and consistently

Method types by Effectiveness

• Best methods: Implants, IUD, female sterilization, vasectomy (0.1% failure rate)
• Better methods: Injectables, LAM, oral contraceptive pills (OCPs)
• Good methods: Male condoms, female condoms, fertility awareness methods
• Least effective methods: Withdrawal, spermicides

Long-Acting Reversible Contraception (LARC) Methods

• Highly effective and reversible with rapid return to fertility after removal
• LARCs have fewer contraindications and don't require frequent visits for resupply.
• Single-rod etonogestrel subdermal implant (Implanon)
• Copper T380A intrauterine device (Cu-IUDs)
• Several levonorgestrel-releasing intrauterine systems (LNG-IUS)

Reversible Contraceptive Methods

• Depot Medroxyprogesterone Acetate (DMPA) given via injection as opposed to LARCs which are long acting
• Progestin-only Pills (POPs)
• Combination Hormonal Contraceptives (CHCs)

Intrauterine Devices

• Chemically active, continually eluting either copper or a progestin
• They have a flexible, T-shape with Barium making them radiopaque for detection via imaging
• Types include progestin-containing (hormonal) and copper devices (CuT380A IUD)
• Copper devices do NOT contain hormones, but they are still chemically active due to copper content
• Copper is thin around stem and is a bracelet on each arm

Contraceptive Actions

• Prevention of Fertilization from the intense inflammatory response, especially with Cu-IUDs
• Fluid fills the uterine cavity and fallopian tubes to decrease sperm and egg viability
• LNG-IUS releases progestin which atrophies the endometrium to hinder normal implantation and creates scant viscous cervical mucus to obstruct sperm motility
• Method-specific adverse effects such as ectopic pregnancy, lost device/embeddedness, perforation, menstrual changes, infection, and pregnancy with an IUD

Contraindications to IUD Use

• Pregnancy/ suspected pregnancy
• Distorted uterine cavity
• Submucous myomas
• Acute pelvic inflammatory disease (PID) and endometritis in past 3 months
• Uterine bleeding of unknown etiology
• Acute untreated lower genital tract (LGT) infection
• Thorough history and internal exam are required
• Conditions linked to pelvic infection risk include multiple partners, immunocompromise, drug use, and recent PID/endometritis
• Allergy to device components and coexisting retained IUD
• Specific to Cu-IUD: Uterine/cervical cancer, Wilson disease
• Specific to LNG-IUS: Prior PID, uterine/cervical neoplasia, acute liver disease, liver tumor, or breast cancer

Timing of Insertion

• Check for contraindications and obtain consent
• Interval: In between pregnancies, wait for 6-8 weeks post-delivery to reduce expulsion rates
• Immediate: Inserted, in the absence of overt infection, during miscarriage, surgical abortion
• Within first 10 minutes after placenta delivery has the highest rates of expulsion within early placement
• Follow interval placement to reduce risk of IUD being expelled
• Insertion post delivery at post-cesarean delivery when uterus is opened using an inserter with lower transverse uterine incision
• Interval insertion can be anytime after the 6-8 weeks of uterine involution period excluding pregnancy.
• Insertion near the end of normal menstruation is easier and excludes pregnancy.

Progestin-Only Contraceptives

• Suppresses luteinizing hormone (LH) to block ovulation
• Cervical mucus thickens to retard sperm passage due to progestin
• Atrophy renders the endometrium unfavorable for implantation.
• Side effects can include irregular or short menses
• Most progestin-only contraceptive methods do NOT significantly affect lipid metabolism, glucose, hemostatic factors, liver function, thyroid function, or blood pressure
• Risks for genital tract, liver, or breast neoplasia are NOT increased
• Relative safety as compared to estrogen-containing due to combined estrogen and progesterone is better in inhibiting ovulation compared to progestin-only.
• Progestin contraindications can be current pregnancy, breast cancer, acute liver disease, liver tumors and undiagnosed abnormal genital bleeding

Etonogestrel Implant

• Etonogestrel Implant is a thin, pliable, progestin-containing cylinder implanted in the upper arm that releases at least 30 µg of hormone daily, for up to 3 years
• Brunches of the medial antebrachial cutaneous nerve and median nerve can be injured during an insertion that is too deep, explore implant removal from nonpalpable devices
• Ideally inserted within 5 days of menses onset, however if a women is not pregnant insertion is followed by an additional backup method for 7 days

Injectable Progestin Contraceptives

• DMPA (depot medroxyprogesterone acetate) is administered 150 mg every 3 months
• Norethisterone enanthate is 200 mg every 2 months and it is not available in the PH
• DMPA Side Effects include prolonged anovulation, endometrial atrophy, hypertension and weight gain
• In long term DMPA users, bone density loss is greater, reason why its not recommend to adolescents.
• Calcium supplements are needed for long term DMPA users.
• "Mini-pills" consists of one-only norethindrone which provides 0.35 mg of progestin and are taken daily
• Does NOT reliably inhibit ovulation, but efficacy arises from cervical mucus thickening and endometrial atrophy
• Drospirenone-only pills delivers 4 mg of drospirenone which have spironolactone with antiandrogenic properties and has antimineralocorticoid properties which may, in theory, cause potassium retention and hyperkalemia
• Contrain 0.075 mg of desogestrel hormone is be used daily and continuously x 28 days for the missed-pill window (12 hours) and (4 hours based from OB’s recommendation)

Combined Hormonal Contraceptives

• Combined hormonal contraceptive pills (COCs)
• These contain both estrogen and progestin.
• The net effect is an extremely effective yet highly reversible contraceptive method.

Composition of Combined Hormonal Contraceptives

• Constant dose of drospirenone paired with 20 µg of Ethinyl estradiol
• Cycle control appears to be similar among mono-, bi-, and triphasic pills

Administration of Combined Hormonal Contraceptives

• One active tablet is taken dialy replacing a placebo at a specified time.
• Expect bleeding prompted by withdrawal during pill free days.
• Common regimens include the Philippines 21-day active pills in packs without a followed placebo 4-7 day pill free.
• 24/4 regimen performs similarly to the 21/7 (24 active +4 placebo)

When to start taking Combined Hormonal Contraceptives

• Taken on the first day of the menstrual cycle requires no use of a back-up method
• Traditional Sunday start includes within 5-7 day 1 of menses and the effective method will be inhibit ovulation which requires backup contraception

Timing and Missed Doses with Combined Hormonal Contraceptives

• Taking the pill everyday at the same time allows maximun effectiveness

Missed dose guidelines

• If one pill is missed take missed pill inmediately, and scheduled dose is taken on time while pills are continued.
• If 2 or more pills are missed take the most recent pill dose while continuing a backup

Non-contraceptive Benefits

• Regulates menstrual cycles
• Reduces the risk of certain cancers
• Treats acne manage PCOS endometriosis/dysmenorrhea

Contraindications

• Elevated hepatic production of sex hormone which binds testosterone and elevates with metabolic changes which may aggravate with underlying conditions and be contraindicated in certain individuals

Vaginal Ring

• Contain 2.7 mg of ethinyl estradiol and 11.7 mg of etonogesterel where steroids easily pass through the vaginal epithelium directly into the circulation.
• A higher dose is required due to local route of administration placing nuvarings in the vagina for 21 days and removed for 7 allowing withdrawal bleeding
• Used for Hormonal that is similiar to COCs.
• Can have effects leading to inhibition to prevent ovulation
• Contracpetive skin patches allow skin to 75 µg ethinyl estradiol and 6 mg norelgestromin placed on the buttocks upper arm while containing skin

Emergency Contraception

• NOT a primary birth control method but taken for following unprotected intercourse is a EC regimens to substantially lower the likelihood of an unwanted pregnancy
• begin dosing as early as possible and ideally within 72 hours of unprotected coitus
• Current methods include:
• Combined
• progestin
• A selective progesterone-receptor modulator
• Single dose levonorgestrel
• Most commonly used are COCs in the Yuzpe method

Emergency Contraception Action

• Inhibition or delay of ovulation and requires no association with major congenitial malfromation or pregnancy

Barrier Methods

• Male condom is commonly readiliy available where used properly with infection protection.
• Provides Contraceptive enhanced to spermicide, adjunct lubricant with spermicide water based and oil based.
• Nonallergenic condoms are effective and condom breakage allow high breakage and slippage

Female Condom

• Contains with nitrile sheath and ring adding Silicone Based Lubricant to create friction

Diaphragm

• Contains Latex material or spermicide applied into the dome which effectively face effectively.
• Central spermicide is held with the cervix where the site allow the dome to be placed in the vagina to hold the rim and prevent urethra

Cervical Cap

• Made of cilin cone to cover the cervix with the site is help the upper muscular cap to prevent pregnancy

Calendar Rhythm

• Period and abstinance where ovulation cycle where there are 3 essential assumptions

Two day method

• Relies on awearness to detect changes

Syptothermal Methods

• Combines changes, body temp and calculations to detect effectivness

Lactation Amenorrhea Method

• Transition method provide benefits to the infant

Coitus Related Method

• Remove penis during ejaculation

Sterilization

• Surgical in the women and men
• Puerpal Sterizlation is known as total Salpingectomy to primary prevent ovarian canc.
• Fallopian blocked by cuying to prevent union

Female Sterilization

• Blocks by preventing unity highly efectice
• Usually not reccomened for uunger

Male Sterilization

• Lumen disrupt which block sperms
• Safer then female and local
• Not immidiayed after interuppted

Summary

• Educational with best methods to allow the patient make inform choices
• Providers give to healthcare inform

Referances cited to assist

• cyclebeats
• Mayo Clinic
• Willaims obstertic
• And Transcribed UPCM