Contraception Methods PDF

COMBINED HORMONAL CONTRACEPTION (CHC) CHC contains 2 hormones: Oestrogen...

COMBINED HORMONAL CONTRACEPTION (CHC) CHC contains 2 hormones: Oestrogen & progesterone. CONTRACEPTIO Available as oral Pills, transdermal Patch or vaginal Ring. They work by inhibition of ovulation via negative feedback on the pituitary with suppression of FSH & LH hormones. N All similar in effectiveness, safety and side effects. Patch applied to the skin for 21 days followed by 7 days hormone free period. Releases 33.9 ug ethynyloestradiol/day & 302 ug DR A SWEEDAN norelgestromin/day. Ring self-inserted vaginally for 21 days followed by 7 days hormone free interval (withdrawal bleeding). Ring releases the lowest dose of the CHC, 15ug ethinyloestradiol/day & 120ug etonogestrel/day. COMBINED ORAL CONTRACEPTIVE PILLS COMBINED ORAL CONTRACEPTIVE PILLS (COCPs) (COCPs) Failure rate is as low as 0.3% with perfect compliance. Most of COCPs nd are low dose containing 15-35ug ethinyl oestradiol and 2 generation progesterone (levonorgestrel, Tricyclic regimen (taking 3 packets without a break) can be norethisterone). recommended in women with dysmenorrhea or headache Traditional COCPs contain 21 pills followed by 7 days pill free during the pill free interval. interval (or 7 placebo tablets) during which withdrawal bleeding will happen. Tailored pill use can be recommended, where women continue Commonly COCPs are monophasic ( same dose of hormones to use the pill until want to start the withdrawal bleeding. throughout), some are phasic (dose varies) without advantage. Missed one pill; to take the missed pill as soon as possible New 3d generation progestogens (desogestrel) & 4th generation andto continue using the remaining pills as usual. (dienogset) have less androgenic effects but associated with higher venous thrombosis risk. Missed 2 pills or more; there is risk of ovulation. Additional COCPs containing 2d generation progestogens recommended contraceptive cover (condom or abstinence) for 7 days. as first choice. If unprotected intercourse happened so emergency contraception is recommended  If women develop SIDE EFFECTS OF COCPs SIDE EFFECTS severe headache or migraine during the Weight gain; there is no evidence that COCPs cause weight OF COCPs use of CHC, changing the contraception gain. method is Some women report nausea, breast tenderness & bloating. recommended. Breakthrough bleeding is common (15%) in the first few If women using COCP month. If not settled, change the pill with different dose of experience headaches hormone can help. If bleeding persist more than 3 month, in the pill free week, investigations to exclude other causes of bleeding (cervical then they may benefit polyp, chlamydia, etc.) from continuing the High blood pressure in small number of women using COCPs. pills to avoid the hormone free week There is no evidence that COCPs can cause loss of libido and This Photo by Unknown Author is licensed under CC BY-SA (tricyclic regimen). mood swings. VENOUS THROMBOEMBOLISM (VTE) & CONTRAINDICATIONS FOR COCPs ARTERIAL DISEASE RISK WITH COCPs Age > 35 and smoking. Risk of VTE is small and related to the oestrogen dose in COCPs. Blood pressure > 160/100 mmHg Risk of is VTT less with COCP containing 2nd generation Deep vein thrombosis (DVT), current or past. progestogens compared to those containing 3d & 4th generation. Myocardial infarction, current or past. The absolute risk is less than that associated with pregnancy: Cerebrovascular accident, current or past. - Risk of VTE is 5/10,000 in nonpregnant non COCP users. Breast cancer. - Risk of VTE is 10/10,000 in COCP users. Known thrombogenic mutation. - Risk of VTE is 29-40/10,000 in pregnant/postpartum. Women using CHC & traveling long distance (more than 3 Multiple serious risk factors for cardiovascular disease. hours) should take appropriate exercise during the journey & consider wearing compression socks. VENOUS THROMBOEMBOLISM (VTE) & ARTERIAL DISEASE RISK WITH COCPs CANCER RISK Arterial disease is less common but more serious & related to age & COCPs associated with slight increased risk of breast cancer during smoking use, which decreases on stopping & similar risk to never used after 10 years of stopping. CHC is contraindicated in women over COCPs associated with increased risk of cervical cancer. Other 35 of age and smoke. factors should be considered such not using condoms, smoking. CHC is contraindicated in women who Reduction on the risk of endometrial cancer & ovarian cancer. Almost suffer from migraine with aura 50% with 10 years use of COCPs. This protection lasts for 15 years (unilateral paraesthesia, weakness, after stopping the pills. aphasia occurring before headache) as Reduction on the risk of colorectal cancer. this is due cerebral vasospasm and The reason of this reduction of cancer risks with COCPs is women may be at risk of stroke if use unknown CHC. This Photo by Unknown Author is licensed under CC BY-SA-NC NON-CONTRACEPTIV E BEBEFITS OF CHC PROGESTERONE ONLY CONTRACEPTION Dysmenorrhea Available as: - Progesterone only pills (POP) Heavy period and irregular cycles - Implants Premenstrual tension syndrome - Progesterone only injectable Hirsutism, Acne - Progesterone releasing intrauterine system Endometriosis and adenomyosis Mechanism of actions: Reduces the risk of ovarian cancer - Thicken the cervical mucus reducing the sperm Reduces the risk of endometrial penetrability. cancer - Inhibit the ovulation (variable effect depends on the Reduces the risk of colorectal method) - Endometrial thinning This Photo by Unknown Author is licensed under CC cancer BY-NC-ND - Reduce fallopian tubal cilia motility (not significant) PROGESTERONE ONLY PILL (POP) MINI PROGESTERONE ONLY PILL (POP) MINI PILL PILL POP need to be taken continuously at the same time every day. Mini pill is over 99% effective if used correctly. There are 3 types of POP: Works by Inhibiting ovulation & thickening the cervical mucus. - Traditional mini pill, containing norethisterone (Noriday) or Mini pill is less effective in overweight women. levonorgestrel (Norgeston), must be taken within 3 hours of Mini pill does not affect lactation and safe during breast feeding. the same time each day. Mini pill can cause irregular bleeding, inter menstrual spotting, amenorrhea or no change in the period. - 12-hour POP, containing desogestrel (Cerazette), must be Mini pill can cause small simple follicular ovarian cyst which is taken within 12 hours of the same time each day. usually asymptomatic and disappears spontaneously. - Drospirenone POP, must be taken within 24 hours of the Antiepileptic drugs, HIV medications & some antibiotics same (rifampicin) can reduce the efficacy of the mini pill. time every day. PROGESTERONE INJECTABLE PROGESTERONE ONLY PILL (POP) MINI CONTRACEPION PILL Contra indications of the Mini pill: Depo-Provera, contains 150mg depot - Breast cancer medroxyprogesterone acetate (DMPA). - Liver disease ( liver cancer, tumour or cirrhosis) Injected every 90 days plus or minus 14 days. Failure rate for DMPA when used properly is 0.1% - undiagnosed vaginal bleeding DMPA is the injectable most widely used worldwide and - Porphyria (avoid progesterone) injected deep intramuscular. *Non contraceptive benefits of mini pill: DMPA is available in lower dose 104 mg called Depo-SUBQ Provera 104 injected subcutaneously every - Treatment of endometriosis 3 months. - Management of heavy period and dysmenorrhea - Other trade names for DMPA are Depo-Prodasome, - Protection against endometrial cancer Megestron and Depo-Clinovir. This Photo by Unknown Author is licensed under CC BY-NC-ND PROGESTERONE PROGESTERONE INJECTABLE INJECTABLE CONTRACEPION CONTRACEPION Progesterone injectables are given by deep intramuscular injection & NET-EN (Norethisterone they work mainly by inhibiting the ovulation & thickening the enanthathate) injectable. cervical mucus, forming barrier to the sperm. Contains 200mg NET-EN & injected DMPA is given every 3 months plus or minus 14 days. subcutaneously every 60 days plus or NET-EN is given every 2 months plus or minus 14 days minus 14 days. Save and suitable during breast feeding. Failure rate when properly used is Up to 90% of women using DMPA injectable experience irregular 0.4%. menstrual bleeding pattern or amenorrhea. NET-EN disrupts bleeding Trade names: Noristerat, Norigest and pattern less than DMPA. others. Proper counselling to women about what to expect and explain that amenorrhea is likely and is not harmful. PROGESTERONE INJECTABLE PROGESTERONE INJECTABLE CONTRACEPION CONTRACEPION Side effects: Small & revisable loss of bone mineral density (BMD) in - Irregular period and breakthrough bleeding. the first few years with no serious health risks (fractures). - Weight gain, in average 1-1.5 kg per year. Cancer risk with DMPA: - Small number of women reported; headache, dizziness, - No association between DMPA and cervical, ovarian acne, and liver cancer. fatigue, breast tenderness, body ache & nervousness. - some studies showed small increased risk of young no evidence to support that they are all due to the women following initial exposure. injectables. - studies confirmed substantial protective effect against - Delay in return to fertility. On average fertility returns after endometrial cancer. 8-9 months. For this reason, injectables are not suitable for short term contraception. PROGESTERONE INJECTABLE PROGESTERONE INJECTABLE CONTRACEPION CONTRACEPION Contraindications of progesterone injectables: Non-contraceptive benefits of progesterone only injectables: - Unexplained vaginal bleeding. - Decrease risk of endometrial cancer. - Breast cancer. - Decrease menstrual blood loss. - Liver disease. - Endometriosis and Dysmenorrhea. - Sensitivity to Depo-Provera. - Depo-Provera reduces sickle cell disease crises. - Osteoporosis. - Depo-Provera reduces catamenial epilepsy seizures. - History of heart attack or stroke. - Decrease risk of ectopic pregnancy. - Depression - Decrease risk of pelvic inflammatory disease (PID). PROGESTERONE IMPLANTS PROGESTERONE IMPLANTS Nexplanon, single road containing 68 mg of 3-ketodesgesterl (etonogestrel) providing contraception for 3 years. Contraindications: - Breast cancer, liver disease, heart Works by inhibiting the ovulation, thickening the cervical mucus attack, clots, stroke & undiagnosed vaginal bleeding. and by thinning the endometrium. Side effects: - Irregular period lighter period. Nexplanon is 4 cm flexible rod, inserted sub-dermally 8 cm - Unpredictable period, heavy period. above the medial epicondyle under local anaesthesia. - Amenorrhea Works immediately if it inserted during first 5 days of the - Tender breast, headache, acne, weight menstrual cycle. gain. ( no enough evidence) Fertility is restored immediately after removal. - Infection at the insertion site. Other implants; - Uniplant (single rod, nomegestrol, lasts 1 year) - Deep insertion. - Jadelle ( 2 rods, levonorgestrel, lasts 3-5 years)  PROGESTERONE-RELEASING INTRAUTERINE PROGESTERONE SYSTEM RELEASING Intrauterine system (LNG-IUS) available in Europe called Mirena and contains 52 mg levonorgestrel. Initially it releases INTRAUTERINE 20 ug levonorgestrel daily. SYSTEM LNG-IUS works by exerting potent hormone (levonorgestrel) effect on the endometrium preventing its proliferation & the MIRENA impanation. LNG-IUS thickens cervical mucus to stop sperm from reaching the egg. It has minimal effect on ovulation. Licensed for 5 years. Over 99% effective. Works immediately after insertion. Fertility returns to previous level immediately after removal. This Photo by Unknown Author is licensed under CC BY PROGESTERONE-RELEASING INTRAUTERINE PROGESTERONE-RELEASING INTRAUTERINE SYSTEM SYSTEM LNG-IUS is safe during breast feeding and can be fitted soon Relative risk of ectopic pregnancy if LNG-IUS fails is increased after birth. but the overall risk of ectopic pregnancy is reduced. Risk of perforation during insertion. The risk is higher when LNG-IUS available in smaller dose of levonorgestrel (13.5 mg) LNG-IUS and known as Jaydess in Europe & Skyla in the USA. Licensed inserted straight after birth. for 3 ys. Its shorter & narrower which make insertion easier Contraindications of LNG-IUS: for nulliparous. - Breast cancer Unpredictable bleeding happens in the first 3 to 6 month after - Liver disease insertion, women should be advised that usually improves and - Uterine anomalies (double uterus, uterine many women will have lighter period or amenorrhea. septum) Reported side effects; Acne, breast tenderness, headache, - Pelvic inflammatory disease. mood changes. (no enough evidence supporting this) - Undiagnosed vaginal bleeding. PROGESTERONE-RELEASING INTRAUTERINE SYSTEM Non-contraceptive benefits of LNG-IUS: - Management of heavy period (menorrhagia) - Dysmenorrhea CUPPER INTRAUTRINE - Endometriosis & Adenomyosis. DEVICE - Fibroids CU-IUD - Endometrial hyperplasia. - Protect against endometrial cancer - As part of hormone replacement therapy. This Photo by Unknown Author is licensed under CC BY CUPPER INTRAUTERINE DEVICE (CU-IUD) CUPPER INTRAUTERINE DEVICE (CU-IUD) There are number of CU-IUDs available, and they vary on size, shape, cupper content and duration of use. Mode of action of CU-IUD: Duration of use: 3 to 10 years depending on the device. - Copper stimulate inflammatory reaction in the uterus Shape; T shaped plastic frame with copper wire around he stem which is toxic to the sperm and the egg. and the arms. Threads attached to the end of the stem and protrudes through the cervix for easy removal. - Interfere with sperm transport - Prevent implantation. Insertion & Removal, watch YouTube videos: CU-IUD is 99% effective and works immediately after insertion. - Fitting the coil (IUD/IUS) NHS Fertility returns immediately after removal of CU-IUD. - Removing the coil (IUD/IUS) NHS CU-IUD is safe during breast feeding. - Having IUD/IUS contraception fitted (video by sexual CU-IUD can be used as form of emergency contraception. health in Plymouth)) CUPPER INTRAUTERINE DEVICE (CU-IUD) CUPPER INTRAUTERINE DEVICE (CU-IUD) Women using CU-IUD may have painful heavy period. CU-IUD can be fitted at any point of the cycle provide no risk of pregnancy. Risk of pelvic infection, usually within 3 weeks after CU-IUD fitting Risk of perforation during insertion is 1/1000 Increased relative risk of ectopic pregnancy if CU-IUD fails but Risk of expulsion is 1/20 in the first 3 months after insertion. After this the risk diminishes. Women should be advised to the overall risk (0.05%) is much reduced compared to general perform self checks for the presence of the threads in upper population risk (1-2%). vagina. If women become pregnant with an IUD in situ, ultrasound scan Missing threads may be due perforation, expulsion or should be done to exclude ectopic pregnancy. pregnancy. However, it is often the case that the threads are just sitting in the cervical canal. Pregnancy test & alterative In case of intrauterine pregnancy with IUD in situ, it is advisable contraception should be given until the IUD place can be that the IUD should be removed before 12 weeks gestation in confirmed by ultrasound & x-ray. view of higher risk of miscarriage, chorioamnionitis and preterm labour. BARRIER CONTRACEPTION FEMALE STERLISATION Condom: - Failure rate up to 24% Laparoscopic sterilisation: - Protect against sexually transmitted diseases & - Occludes the fallopian tube with Filshie clips. HIV. - Permanent method of contraception (valid consent) - Female condom is inserted into the vagina. - Failure rate 1/200 (risk of ectopic) Diaphragm and Cap: - Contraception is required until the menstrual period - Cap is inserted over the cervix - 1/1000 risk of injury to bowel, bladder, blood vessel - Diaphragm form a hammock between posterior fornix - YouTube videos: and the symphysis pubis. * Laparoscopic tubal ligation with filshi clips (Akol Endoscopy) - Often used with used in conjunction with * SELS: Laparoscopic tubal ligation with filshi clips spermicides - Failure rate in the region of 18%. FEMALE STERLISATION STERILSATION Tubal ligation can be done during caesarean section. Vasectomy: High proportion of women regret sterilisation specially under the - Permanent occlusion of the vas deferens. age of 30, after miscarriage or given birth. - Outpatient procedure under local anaesthesia. Hysteroscopic sterilisation; which can be done as outpatient - Post vasectomy semen analysis should be done at procedure involves inserting strings (Essure) into the tubal ostia 12 weeks to confirm azoospermia. Alternative via hysteroscopy. This will induce fibrosis within the corneal part contraception should be used during this period. of the fallopian tube over 3 months. Contraception is required - Failure rate 1/2000 (less than female sterlisation) for 3 months and can be stopped once correct placement is - Vasectomy is safer, quicker with less morbidity than confirmed by Xray. laparoscopic sterilisation. Failure rate of hysteroscopic sterilisation is 1/500 EMERGANCY CONTRACEPTION (EC) EMERGANCY CONTRACEPTION (EC) CU-IUD: - Most effective method of EC (failure rate 1/1000) Ulipristal : - Ulipristal acetate (UPA) is a progesterone receptor - Prevents implantation modulator. - should be inserted up to 5 days after unprotected - Ulipristal 30mg given orally up to 120 hours intercourse after Levonorgestrel (LNG): unprotected intercourse. - Works by delaying ovulation - LNG 1.5mg given orally as a single dose (or 2 doses of - Failure rate is 1.2% 0.75mg 12 hours apart) *Yuzpe method involves taking high dose of COCPs foe EC. - It is effective up to 96 hours after unprotected intercourse. 2 doses of 100ug ethinyl estradiol plus 0.5mg of LNG 12 hours apart , given orally as early as possible. - Works by delaying ovulation. It is effective up to 120 hours after unprotected intercourse. - Pregnancy rate is 1.2 to 2.1% It is less effective and less tolerated than other forms of EC NATURAL FAMILY PLANNING GYNAECOLOGY by ten teachers Lactational amenorrhea is Associated with anovulation NICE on Contraception for the first 6 month. RCOG, Guidance on the provision of Coitus interruptus (withdrawal) Further contraception by maternity services after childbirth during the COVID-19 pandemic Calendar rhythm (Standard days method) readings Fundamentals of Obstetrics and Temperature monitoring Gynaecology Cervical mucus method Personal fertility monitor, hand-held monitor analyses THANK YOU the presence of LH & oestrogen metabolites in urine dipstick.