COCs

Progesterone only contraceptives Intra uterine device

[Combined oral Contraceptives] POPs Long acting Subdermal (IUD/IUCD)
[Prog. only Pills] injectables implants
Generations =Minipills =PICs Norplant Non-medicated IUD
EE2 Gestagens Contain gestagen 6 match sized capsules (inert)
only → mainly (LNG) -Obsolete now
1st generation
50 µg 1st generation Depot-provera Gestagen LNG -Polyethylene & barium only
mostly 30µg
gestagens[NET] [DMPA] [levonorgestrel] 1-Lippes loop
nd
2 generation 30 -35 2nd generation 150 mg, every 3m' Duration  5 y' double S-shaped + 2 nylon
e.g, Microlut: 35pills
gestagens[LNG] Noristerat threads
3 generation 20 -30 3rd generation
rd  [NET-EN] Implanon less effective
200 mg, every 2m' inserted by pushing tech. (high
gestagens 1 rod capsule
incidenc of perforation)
[desogestril, [4cm X 2mm]  life long
norgestimate & Gestagen  2-Safe T-coil &Dalkon Shield
gestodene] Etonogestrel
Medicated IUD
Types & Composition

th 20 -30 [3-keto-desogestril]
4 generation drospirenone (active)
in a rate of 40 mg/d'
(Yasmin) -Used nowadays
Duration  3 y' -Polyethylene & barium + loaded
Types
with certain material May be:
Monophasic (same dose of EE2 & gestagen)
EE2 Dose Use
Javelle 1-Cupper medicated
as norplant but 2 rods  Types
high dose pills > 50 µg Emergency -cupper T T2oo, T220, T380 A
(HDP) contraception (most used)
moderate dose 50 µg Not used now (No. represent SA of cupper wire)
pills (MDP) -cupper 7 200
‐multiload  350, 375
low dose pills 20-30 µg used now -cupper & silver  nova –T
(LDP)  more effective.
Biphasic pills (not used now)  inserted by withdrawal tech.
7d' 14d' (less perforation)
EE2 =ethinyl estradiol
 duration for 10 y
EE2 30 30 µg NET=norethisterone family 2-Progesterone medicated
NET 0.5 1 mg NET-EN= norethisterone enanthate (merina) (IUS)
Triphasic pills (not used now) LNG= levonorgestrel T-shaped with progesterone in
6d' 5d' 10d' Oral MPA [Provera] =medroxy progesterone acetate vertical limb (duration 5 y)
EE2 30 40 µg 50 Injection  DMPA [Depo MPA or Depo Provera] 3-Anti-fibrinolytic
LNG 50 75 µg 125 medicated

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 Progesterone only contraceptives
COCs Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives] POPs Long acting Subdermal
[Prog. only Pills] injectables implants
 Central [Estrogen& progesterone] Polyethylene & barium
Central
Estrogen (-ve) feedback e' FSH components
(-ve) feedback e' LH → (--) ovulation → [anovulation]
Progesterone  (-ve) feedback e' LH Local sterile inflammatory
Both  (--) ovulation  [anovulation] reaction in endometrium
Peripheral -swollen, edematous, devitalized
 hostile cervical mucous not suitable for penetration
 Peripheral [Progesterone] endometrium Not suitable for implantation.
 atrophic endometrium not suitable for implantation -↑ acidity in endometrium→ hostile for
 hostile cervical mucous not suitable for
 ↓ motility of the tubes. Sperms &early developed zygote
penetration
 atrophic endometrium not suitable for -↑ Mφ (engulf sperm or early zygote)
implantation -Leucocytic infiltration
 ↓ motility of the tubes Local PGs release
Mechanism of action

(less effect as estrogen is antagonistic) Uterine Contraction &  Tubal Motility

-Prevention of implantation
-expulsion of early implanted ovum
Mechanical factor
Dislodge the zygote
Medications
1-Cu 
-↑ local sterile inflammatory reaction
-↑ Mφ release
- Disturb the enzymes & glycogen
metabolism of endometrial cells needed
for growth of implanted zygote
- Silver [ ↓ fragmentation of Cu ]→
prolong of life span of IUD
2-Progesterone 
-As a Contraceptive  see periph action of
POPs
-As a ttt of DUB see DUB
3-Antifibrinolytics 
-↓ bleeding with IUD

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 Progesterone only contraceptives
COCs Intra uterine device (IUD/IUCD)
POPs Long acting Subdermal
[Combined oral Contraceptives] [Prog. only Pills] injectables implants

Initiating Initiating Insertion

During 1st 7 days of the cycle Timing
(preferably on 1st day of menses)
During 1st 7 days of the menstrual cycle
At any time provided that
(preferably on 1 day of menses)
st
During last few days of the
cycle because
pregnancy is surely excluded
At any time provided that pregnancy is surely 1- Pregnancy is excluded.
Postpartum: excluded 2- Cx is still opened 
Non-breastfeeding women → easy & painless Insertion
Delay until 6 wks after birth
Postpartum
Non-breastfeeding women → after 3 wks 3- Spotting after insertion is
(d2 high postpartum risk of DVT)
Breastfeeding women → mistaken as menses
Breastfeeding women →
Delay until 6 m' after childbirth Delay until 6 wks after childbirth At any time provided that
or until breastfeeding is discontinued Post abortion: → Start immediately or within pregnancy is surely excluded
(Estrogen component ↓↓ breast milk) 1st 7 days after abortion Postpartum
Post abortion: → Start immediately ⓐImmediate postpartum
or within 1st 7 days after abortion Schedule
-Take 1 pill/day DMPA  Norplant  after delivery of placenta or CS
How to use

Schedule until all pills in Injection implants / 5 y'

Advantages
Whatever type of pill  -Cx is fully dilated easy painless
pack finished /3m' ± 2 wk Implanon Insertion
-take 1 pill every day till all pills in pack &repeat again implants / 3 y'
(not > 2 wks to -Spotting after insertion is mistaken
are finished (21 pills) èout break. maintain efficacy) e' Lucia
-then rest for 7 d' [during w' withdrawal -Taken èin 3 h' NET-ET  Disadvantages
bleeding "pseudomenstruation" occurs] of same time Injection  Incidence of infection, inflam,
-then start again each day /2m' ± 2wk displacement & perforation
Missed pill regimen (not > 2 wks to
maintain efficacy)
ⓑDelayed postpartum: →
Missed 1 pill After 4 wks of birth (vaginal or C/S)
■Take missed pill as soon as Missed pill regimen for POPs Insertion Post abortion: → Immediately or
remembered. Late in taking pills > 3 h' By minor surg after 4 wks of abortion
■ Keep taking remaining pills ⓐBreast feeding within 1st 6m' technique using
on schedule special applicator Methods
■ No need for backup method
ⓑNot breast feeding or > 6m'
Removal Pushing tech.(e' Lippes)→ ↑ incidence of
perforation
Missed ≥2 pill By minor surg Withdrawal tech.(e' other types) → ↓
■Take 1 pill immediately & the other technique incidence of perforation .
next day
■ Backup method for 48h' removed at date

■ Take remaining as usual

or on request
Implanon  easier
Removal
in removal & Removed after expiry e.g, Cu-T 380 A → 10y'
■ Backup method for 7 d' Insertion

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 COCs POPs Long acting Subdermal
Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives] [Prog. only Pills] injectables implants
Contraceptive Use Contraceptive Use Contraceptive Use
females 20-35y' if not C/I -in lactating mothers
-lactating -in lactating mothers if preg. spacing
-if age > 35 y'
Non-Contraceptive Use -if age > 35 y' -if age > 35 y' for many years
1-DUB or terminal
-Female refusing hormonal
-if COCs is C/I -if COCs is C/I contraception
2-Endometriosis. contraception
3-Hirsuitism -In multipara having children (never
-if pregnancy spacing in nulligravida as it causes PID)
4-Spasmodic dysmenorrhea. >1 y or Terminal
5-PMS 6-Acne contraception
Non-Contraceptive Use
7-Functioning ovarian cyst 1-DUB by prog. & antifibrinolytic IUD
Indication

-sickle cell disease

8-Postpone menstruation [↓↓ frequency & severity of crisis] 2-After adheseolysis in Asherman's
-Epilepsy syndrome by Lippe's IUD
[↑↑ seizers threshold & not [only indication of Lippe's nowadays]
affected by antiepileptic drugs]

Non-Contraceptive
Use
1-DUB
2-Endometriosis.
3-Hirsuitism
4-Endometrial Carci
5-Fibroid.
6-Precoicous puberty
Effectiveness

Use Failure = 1-2 /HWY

Use Failure =
Method failure = 0.1 Use Failure  < 1 /HWY Use Failure = 2-4 /HWY
MC cause of failure  incorrect use 2-4 /HWY
Nearly as tubal sterilization

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 COCs POPs Long acting Subdermal
Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives] [Prog. only Pills] injectables implants

ⓐGeneral advantages  from Scheme

General advantages of any Contraceptive methods Except in…….
Effective*  Reliable POPs
Easy to use*  Reversible [Rapid return fertility] Progesterone only injectable
Cheap*  Available
Safe [ S/E]  No need medical supervision COC
Not affect sexual relation Accepted by couple
*Subdermal Implant  Not Cheap & Not easy to use [Inserted, removed by minor surgical technique]
Advantages

*IUD  Not Effective [High failure rate] & Not easy to use [need doctor for Insertion & removal]
l
ⓑRisk of ⓑSuitable for Lactating mother & When COCs are C/I ⓑSuitable for Lactating mother &
1-Ovarian & endometrial cancers ⓒRisk of When COCs are C/I
2-Bg breast dse
3-Ectopic pregnancy 4-PID 1-Ovarian & endometrial cancers
5-Anemia. 2-fibroids 3-↓ Endometriosis symptoms ⓒNon-Contraceptive use
6-Menst. Irregularities 4-Ectopic pregnancy 5-PID.
6-↓ frequency & severity of sickle cell crisis ⓓDurable & can be removed at
ⓓNon-Contraceptive use ⓓDurable & can be any time e' rapid return of fertility
ⓒNon-Contraceptive use
removed at any time
e' rapid return of
fertility

ⓐRequires regular daily intake ⓐRequires ⓐ Inability to ⓐ Minor surgical ⓐInsertion & removal need
& resupply. regular daily withdraw the drug interference & trained HCW
Incorrect use & missed pills are [Contraceptive effect &S/E can't be Complications 
……… ⓑLess Effective
Disadvantages

stopped immediately] Abscess & difficult

common → ↓↓ efficacy removal d2 fibrosis
ⓑ Delayed return of fertility ⓑLess ⓑDelayed return of ⓑCosmetic or
(May reach 3 m') Effective fertility (at least 4 m')
tender

ⓒNo protection against STDs including HIV

ⓓ Side effects (‫)تُكتب‬
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 COCs POPs Long acting Subdermal
Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives] [Prog. only Pills] injectables implants
Menstrual disturbances Menstrual disturbances Menstrual disturbances
MC & the main cause of discontinuation.
ⓐBleeding  MC complication
Anticosmotic effect 1) Breakthrough bleeding or spotting.
2) Amenorrhea. mainly menorrhagia
Wt gain,
Skin pigmentation & Acne 3) Heavy or prolonged bleeding ‫تكتبُمعُ؟؟‬ A/E -IUD disturb PGs → 2ry DUB
Alopecia Wt gain & Depression -local causes e.g, polyp .
Pseudopregnancy state  incidence of Breast enlargement & ttt 
exclude local causes then deal as 2ry DUB
E2 Progesterone ectopic pregnancy mastodenia
(may give prog. medicated IUD)
Nausea, -Loss of d2  motility of Bone density
vomiting, appetite tubes ⓑAmenorrhea [Missed period]
( Risk osteoporosis)
headache -Depression IUD +Missed period 
dizziness
Carcinogenesis pregnancy until proved otherwise &
[controverse] this pregnancy is ectopic till proved
-Overall incidence is
S/E [risks-Complications]

Breast effect otherwise.

not ed, but ↑ may -If pregnancy excluded → it's a case
- Suppression of lactation be d2 early diagnosis
- Breast tenderness of 2ry amenorrhea (IUD has no role)
since regular visits or
-↑ incidence of cancer breast pre-existing breast Insertion complications
-↓ incidence of Bg breast lesion cancer vaso-vagal attack, perforation,
Oncogenic effect failure of insertion
- ↑ incidence of cancer breast if Expulsion
used before 36 y'
- ↑ Bg & Mg Tm of the liver
Extraction difficulties
- ↑ incidence of fibroids &
endometriosis [HDP]  PID & Pain
- ↑ risk of invasive cancer Cx Discharge [serous, serosanginous or
if used >5 y' mucous]
may be d2 other factors e.g, smoking &
multiple sexual partners
 Failure (Pregnancy)
Threads
Inability to feel threads (missed IUD)

Discomfort of male d2 very long

Threads

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 COCs Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives]
Fertility Perforation Expulsion PID Pain
- Delayed 3m' after stoppage of pills Mainly d2 faulty -unskilled -Septic IUD Low backache MC
Teratogenic insertion provider -Pelvic pelvic congestion &
if given in 1st trimester -postpartum Actinomycosis Israeli Cx erosion .
causing anomalies in insertion -threads act as a Acute abdominal pain
Vertebral bodies & Limb -high parity ladder d2 perforation , acute
Esophageal, Tracheal &Anorectal, -nulliparity
PID & ectopic
Cardiac & Renal -big IUD Incidence pregnancy .
Metabolic effects -closed IUD 1.5 times > normal
Chronic lower

A/E
-Proteins  anabolic →↑ weight (E2) (specially in 1st m'
after insertion). abdominal heaviness
-CHO  diabetogenic (E2) d2 chronic PID &
-Fat  ↑ LDL & ↓ HDL (progesterone) pelvic congestion .
Uterine cramps &
-Clotting  ↑ clotting (E2)
S/E [risks-Complications]

dysmenorrhea
-H2O  salt & water retention → ↑ wt. (E2) d2 abnormal position
CVS effects inside uterus
-E2 → ↑ incidence of thrombosis, salt &
acute abd. pain -Irreg see PID
water retention
during insertion bleeding
-Progesterone → ↑ incidence of -vaginal spotting -Pain tubal adhesions →
C/P

atherosclerosis localized -Pregnancy infertility (never used

So, ↑ incidence of -IHD -Systemic Vascular peritonitis in nullipara)
occlusions - HTN [e' medicated]
-DVT & Pul. embolism See missed IUD Loop extraction & ttt ttt of the cause &
CNS effects
ttt

of PID analgesics
- ↑ incidence of headache, migraine & mood
changes
- ↑ incidence of cerebral strokes
Failure of IUD (Pregnancy) (missed period)
-IUD + amenorrhea → pregnancy until ………….(1/30 pregnancies).
⓫GIT effects -If pregnancy is extrauterine  ectopic preg.→ deal as ectopic pregnancy
- Nausea, vomiting & malabsorption
- ↑ incidence of gall stone formation, -If pregnancy is intrauterine  pregnancy on top of IUD
cholecystitis, hepatic Tm A/E -Perforation -Expulsion -low insertion of IUD -Expiry
- Cong. anomalies of uterus e.g, bicornuate uterus .
Risks abortion : septic abortion till proved otherwise.(50%)
preterm labor (4 times ↑ risk) & no ↑ risk of congenital anomalies .
Management
if threads accessible→ immediate removal & follow up (↓ risk of abortion to 25 %)
if not accessible→ leave IUD & follow up as high risk pregnancy
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 COCs Intra uterine device (IUD/IUCD)
[Combined oral Contraceptives]
⓬Drug interaction Missed IUD [ Inability to feel threads]
▶ Drugs that ↑ activity of hepatic Definition
microsomal enzymes → ↑ destruction E2 & Patient unable to feel the threads
Progesterone → ↑ failure rate A/E
e.g, Rifampicin, tetracycline, sedatives, Deep vagina + short fingers Adherent threads to vaginal wall or Cx Cut threads
hypnotics
Pregnancy  Expulsion  Perforation Abnormal position of IUD in uterus
▶↓ Action of 
Anticoagulants. Management
Antidiabetic [oral hypoglycemics] Careful Vaginal examination [PV & speculum]
Antihypertensive 
Threads are present Threads are not present
Thread not felt d2 d2 one of the following
Deep vagina + short fingers
S/E [risks-Complications]

Pregnancy
Adherent threads to vaginal wall or Cx  Expulsion
Cut threads  Perforation
Abnormal position of IUD in uterus

Continue by the following investigations

1-Pregnancy test  +ve  Pregnant

-ve Do Pelvi-abdominal x-ray

2-Pelvi-abdominal x-ray IUD not Seen Expulsion

IUD seen Do Old or recent methods
3-Plain x-ray + sound intrauterine[ If overlapping in x-ray e' sound Intrauterine IUD]
or HSG [old methods]
TVS or Hysteroscope [recent methods]

Intrauterine IUD  Perforation

Laparoscopic removal or If not removed mini laparotomy & removal + repair of any injury
Extrauterine IUD  Abnormal position of IUD in uteru
Try to remove by Bozeman's forceps or Novack currette
If not removed hysteroscopic extraction (or D & C if no hysteroscope available) 8
 POPs Long acting Subdermal
COCs [Prog. only Pills] injectables implants Intra uterine device (IUD)
Pill-danger sign Abdominal pain Weight gain pain (severe abdominal pain
[Indications to stop]
Warning signs

Abdominal pain (may be MVO) (may be ectopic preg.) Depression may be ectopic pregnancy)
Chest pain (may be pul. embolism) Missed period Heavy vaginal bleeding  Amenorrhea (may be
(may be pregnancy) pregnancy)
Severe Headache Headache
(may be prodroma of cerebral stroke) Inability to feel the threads
Eye symptoms Noticeable discharge e' fever
(may be retinal artery occlusion) (infection)
Absolute C/I
WHO MEC*  category 4 WHO MEC  category 4 WHO MEC for starting WHO MEC for starting IUD 
injectable  category 4 category 4
1-Pregnancy 2-Unexplained vaginal bleeding. 3-Breast cancer 1-Pregnancy
2-Unexplained vaginal bleeding.
4-Breastfeeding < 6 wks after 4- Breastfeeding <6wks
3-Cx, endometrial or ovarian
childbirth after childbirth
cancer.
5- Heavy smokers 5- Current ttt with ABx
4-Current or recent PID, STDs,
6-Complicated diabetes. (rifampin, griseofulvin)
septic abortion or pelvic TB.
7-Severe HTN or AED
5-Distorded uterine cavity
8-Current or past Hx of IHD 6-Gallbladder dse.
9-Current or past Hx. of 7-Active liver dse,
thromboembolism . cirrhosis, liver Tm
10-Valvular Ht dse e' complication.
11-Past thrombo-vascular accidents.
C/I

12-Prolonged immobilization
13-Migraine. *Standard abbreviation for Medical Eligibility Criteria
14-Epilepsy. AED =Antiepileptic drugs
15-Active liver dse, cirrhosis, liver Tm

Relative C/I
WHO MEC category 3 WHO MEC for starting WHO MEC for starting IUD 
1-Age ≥35 injectable category3 category 3
2-light smoker. 1-Breastfeeding <6wks
3-Breastfeeding 6w'- 6m' postpartum 2-Severe HTN 1-Risk of developing STDs
4-Non-breastfeeding women 3wk 3-Complicated diabetes. 2-HIV/AIDS infection.
postpartum [after childbirth] 4-Current or past Hx of IHD
5-Mild and moderate HTN 5-Past thrombo-vascular
6-Certain ABx or AED** accidents.
7-Gallbladder diseases 6-Active liver dse, cirrhosis,
liver Tm 9