L20: Contraception

1. Characteristics of ideal contraceptive method

 Highly effective
 No side effects
 Cheap
 Rapidly reversible
 Widespread availability
 Acceptable to all cultures and religions
 Easily distributed
 Can be administered by non-health care personnel

2. Efficacy of contraception

Contraceptive Method Failure rate per 100 women years

COCP 0.1 – 1
Progestogen-only pill 1–3
Depo-Provera 0.1 – 2
Implanon 0
Copper-bearing IUD 1–2
Levonorgestrel-releasing IUD 0.5
Male condom 2–5
Female diaphragm 1 – 15
Persona 6
Natural Family Planning 2–3
Vasectomy 0.02
Female sterilization 0.13

3. Classification of Contraception

Classification Contraception
Hormonal Contraception  COCP
 Combined Hormonal Patches
 Progestogen-only Contraception (POP, Injectables, Subdermal
implants, Hormone-releasing Intrauterine System)
Intrauterine Contraception  Copper IUD
 Hormone-releasing intrauterine System
Barrier methods  Condoms
 Female barriers
 Spermicides
Coitus interruptus (withdrawal)  Pull out method
Natural Family Planning  Abstinence between the fertile period
 Breastfeeding
Emergency contraception  Morning after pill (Levonorgestrel & Ulipristal)
Sterilization (Permanent)  Female sterilization
 Vasectomy

4. Long-Acting Reversible Contraception

a) Definition
Methods of contraception with extended effect more that 1 month

b) Types
 Intrauterine contraception
- IUD and IUS
 Injectables
 Subdermal implants (3 years)
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Hormonal Contraception

1. Combined Oral Contraceptive Pills

a) What is it?
 Contains a combination of 2 hormones
- Synthetic estrogen
- Progestogen (Synthetic derivative of progesterone)
 Contains 21 pills (1 pill to be taken daily followed by a 7-day pill-free interval)
- There are also some every-day (ED) preparations that include 7 placebo pills or iron pills that are
taken instead of the 7 pill-free intervals
 Preparations
- Monophasic pills (standard daily dosages of estrogen & progestogen)
- Biphasic or Triphasic preparations (2 or 3 incremental variations in hormone dose)

b) Commonly used preparations

Estrogen  Ethinyloestradiol (20µg, 30µg, 35µg, 50µg)
 Mestranol (50µg)
Progestogen Second Generation Norethisterone acetate (0.5mg, 1.0mg, 1.5mg)
Levonorgestrel (0.15mg, 0.25mg)
Third Generation Gestodene (0.075mg)
Desogestrel (0.15mg)
Norgestimate (0.25mg)
Anti-mineralocorticoid Deospirenone (3mg)
& Anti-androgenic

c) Mode of action
Central Estrogen & Progestogen  Suppress FSH & LH (secreted by pituitary)  Inhibiting ovulation
Peripheral 1) Make endometrium atrophic & hostile to an implanting embryo
2) Altering cervical mucus to prevent sperm ascending into the uterine cavity

d) Side effects
Central Nervous System Depression, Headaches, Loss of libido
Gastrointestinal System Nausea & Vomiting, Weight gain, Bloatedness, Gallstones, Cholestatic Jaundice
Genitourinary System Cystitis, Irregular bleeding, Vaginal discharge, Growth of fibroids
Breast Breast pain, Increased risk of breast cancer
Miscellaneous Chloasma (facial pigmentation), Leg cramps
***Ideally discontinue COC at least 2 months before any elective pelvic of leg surgery

e) Contraindications
Absolute Relative
 Circulatory diseases  Generalized migraine
- IHD, risk factors for CVD  Long-term immobilization
- CVA, VTE  Irregular vaginal bleeding (until a
- Any acquired/inherited pro-thrombotic therapy diagnosis has been made)
- Significant Hypertension  Less severe risk factors for CVD (e.g.,
 Acute or Severe Liver disease obesity, heavy smoking, diabetes)
 Estrogen-dependent neoplasms (breast cancer)
 Focal migraine with aura

f) Drug interaction
 Can occur with enzyme-inducing agents (e.g., Anti-epileptic drugs)
- Anti-epileptic drugs  Higher dose estrogen pills containing 50µg Ethinyl Estradiol may be needed
 Broad-spectrum antibiotics can alter intestinal absorption of COC and reduce its efficacy
- Additional contraceptive measures (condom) should be recommended during antibiotic therapy and for
1 week thereafter
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g) Positive health benefits
 Treat heavy or painful periods
 Improve premenstrual syndrome (PMS)
 Reduce the risk of PID (Alter cervical mucus)
 Treatment for acne
 COC offers long-term protection against both ovarian and endometrial cancers

h) Management
 Detailed past medical & family history should be taken
 Check BP before COC prescribed
 Routine weighing and BMI calculation
 Careful teaching and explanation of the method & supplemented by information leaflets
 Women need clear advice about what to do if they miss taking their pills

2. Combined hormonal patch (Evra)

a) What is it?
 Transdermal patch containing estrogen & progestogen
- Releases Ethinylestradiol 20µg and Norelgestromin 150µg per 24 hours
 Patches are applied weekly for 3 weeks, after which there is a patch-free
week
 Contraceptive patches have the same risks and benefits as COC

3. Combined hormonal vaginal ring (NuvaRing)

a) What is it?
 Made of latex-free plastic ring of diameter 54mm and 4mm thickness
 Releases daily Ethinyl Estradiol 15µg and Etonorgestrel 120µg
 Inserted in the vagina for 21 days and removed for 7 days during which
withdrawal bleeding occurs
 It has the same risks and benefits of COC
 Has excellent control of menstrual cycle

4. Progesten-only contraception
a) Definition
 Does not contain estrogen
 They are extremely safe and can be used if a woman has cardiovascular risk factors and breastfeeding

b) What is it?
 Second generation – Norethisterone or Norgestrel (or their derivatives)
 Third generation – Desogestrel within 12 hours (window)
 POP is taken every day within 3 hours (window) without a break (non-cyclic)
 Failure rate POP > COC, Failure of POP  Slightly higher risk of ectopic pregnancy
 Ideal for women at times of lower fertility

c) Type
 Progestogen-only pill or ‘mini-pill’
 Subdermal implant
 Injectables
 Hormone-releasing Intrauterine System (IUS)

d) Mode of action
Central Higher dose progestogen-only methods  Inhibit ovulation
Peripheral 1) Cervical mucus  Thick and hostile to ascending sperm
2) Endometrium  Thin and atrophic  Prevent implantation and sperm transport

e) Side effects
 L20: Contraception
 Irregular or absent menstrual bleeding (non-cyclical)
 Functional ovarian cysts
 Breast tenderness
 Acne

f) Indications
 Breastfeeding
 Older age
 Cardiovascular risk factors
 Diabetes

5. Injectable progestogens

a) What are the 2 injectables?

 Depot medroxyprogesterone acetate 150mg (Depo-Provera)
- Lasts 12 – 13 weeks
 Norethisterone enanthate 200mg (Noristerat)
- Only lasts 8 weeks

b) Benefits of Depot Provera

 Highly effective method of contraception
 Improve Pre-menstrual syndrome
 Can treat menstrual problems (e.g. Dysmenorrhea, Menorrhagia)
 More convenient for women (can miss pills)
 Can be used with breastfeeding

c) Side effects of Depot Provera

 Weight gain of around 3kg in the first year
 Almost 6 months delay in return of fertility
 Persistent menstrual irregularity
 Very long-term use may slightly increase the risk of osteopenia and osteoporosis (because of relative
low estrogen levels)

6. Subdermal implants (Implanon)

a) What is it?
 Single silastic rod to be inserted subdermally under LA into the upper
arm
 It releases progestogen

b) What are the progestogens

 Etonogestrel 25 – 70µg daily (dose released decreases with time)
- Etonogestrol is metolbalized to 3rd generation progestogen (Desogestrel)
 Nexplanon (radio Opaque)

c) Benefits
 Lasts for 3 years and can be easily removed and further implant can be inserted
 Useful for women who have difficulty remembering to take a pill
 Suitable for women who want highly effective long-term contraception
 There is rapid return of fertility when it is removed

Intrauterine contraception (IUCD)

 L20: Contraception
a) Advantages
 Highly effective
 Ideal for women who want a medium to long term method of contraception
 Regular compliance is not required
 IUD protect against both Intrauterine & ectopic pregnancy

b) Types
Non-Hormonal (Copper IUD) Hormonal (Mirena)
 Multiload 250 (effective 3 years)
 Multiload 375 (effective 5 years)

 Nova T (effective 5 years)

 Mirena
- Contain 52mg levonorgestrel around its stem which
releases a daily dose of 20 µg of hormone

 Copper T 380A (effective 10 years) About

 Associated with dramatic reduction in menstrual blood
loss
 Licensed for contraception
 Treatment for HMB
 Part of HRT regimen

c) Differentiate between Copper IUD and Mirena

Copper IUD Mirena
0.8% Failure Rate in 1st 0.1%
year of use
0.8% Risk of Ectopic 0.1%
Toxic effect on both sperm & egg MOA Local hormonal effect on the cervical mucus
(i.e acting prior to fertilization) and endometrium
10 years Duration of use 5 years
Heavier periods + More pain Effect of Irregular periods but lighter, Amenorrheic
Menstrual cycle
More days of spotting before and Menstrual Erratic spotting very common initially but
after periods spotting usually settles
None Hormonal Side Greasier skin, Acne, Breast tenderness, Mood
Effects swings (Symptoms usually settle with time)
None Therapeutic Helps heavy & painful periods
Benefits Part of HRT regimen

d) Contraindications of IUCDs
 Current STI or PID
 Malignant Trophoblastic Disease
 Unexplained Vaginal Bleeding (before assessment)
 Endometrial & Cervical cancer (until assessed and treated)
 Known malformation of the uterus or distortion of the cavity (e.g., fibroids)
 Copper allergy (but could use a Mirena)

e) Complications
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 Infection (PID)
- Small ↑ risk of PID in the first few weeks after IUD insertion but antibiotics are not routinely given
- Mirena users have risk of PID due to hormonal protective effect (thickened cervical mucus)
- IUD does not protect against PID comparatively with condom users

 Ectopic pregnancy
- Copper IUD risk = 0.8%, Mirena risk = 0.1% (Total Failure Rate = Intrauterine & Ectopic pregnancies)
- Copper IUD risk of ectopic <1.5 per 1000 woman-year using IUD

Barrier methods of contraception

a) About
 Barrier to the sperm reaching and fertilizing the egg
 Used in conjunction with a hormonal method or IUD
- Hormonal method or IUD  Personal protection against infection and ↑ contraceptive efficacy

b) Types
Condom  Made of latex rubber with varying sizes, shapes, different textures, flavours,
colours and scents
 Emergency contraception can be used in the event of a condom bursing or
slipping off during intercourse
 Note that some men & women may be allergic
 Men must be instructed on how to apply condoms before any genital contact
and to withdraw the erect penis from the vagina immediately after ejaculation
Female Barriers  Diaphragm & Cervical Caps s
 Diaphragm - Should be used in conjunction with a spermicidal cream or gel
 Cervical Caps - Inserted immediately prior to intercourse & should be removed at least 6
 Female hours later
Condom  Female barriers offer protection against pelvic infection, but increases the risk
of UTI and vaginal irritation
 Female condoms
- Made of plastic and are also available
- Less likely to burst
- Couples fins them anesthetic
Spermicides  Product: Gel, Pessary, Foams, Creams
 Contains active ingredient nonoxynol-9
 Designed to be used with another barrier method to make them more effective
 Nonoxynol-9 may provide protection against some STIs, but a recent concern
has been the finding of a higher risk of HIV transmission in frequent spermicide
users (unprotected sex)

Withdrawal (Coitus interrupts)

 Penis is removed from the vagina immediately before ejaculation takes place
 Not particularly reliable, as pre-ejaculatory secretions may contain millions of sperm
 Young men often find it hard to judge the timing of withdrawal
 The use of emergency contraception should be considered if a couple have used withdrawal

Natural family planning

Abstinence during  High failure rate as difficult to abstain when required

the fertile period  Fertility period
- Changes in basal body temperature, Changes in cervical mucus, Track cycle days,
Combined approaches
Breastfeeding 98% protection if fully (excessively) breastfeeding during first 6 months

Emergency Contraception
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Hormonal  MOA – Disruption of ovulation or corpus luteal function, depending on the time in cycle
 Levonorgestrel (Prostinor) – 1.5mg
- Within 72 hours of unprotected intercourse
- The earlier it is taken the more effective it is
 Uripristal (EllOne) – 30mg
- It is a Selective Progesterone Receptor Modulator (SPRM)
- Within 120 hours of unprotected intercourse
IUD  Copper IUD
- Prevents implantation when inserted up to 5 days after a single episode of unprotected intercourse
Or
- Prevents implantation when inserted up to 5 days after the calculated earliest day of ovulation
covering multiple episodes of intercourse in the same menstrual cycle

Sterilization (Permanent methods of contraception)

 Epidemiology
- Done in 50% of couples above 40 years old
- Sterilization can be reversed, with 25% subsequent successful pregnancy rates
- Regret rate 10 – 15%, more common below 30 years old
- Suitable for couples who are sure that they have completed their families or carry an inherited dsorder
 Written constant (preferably for both partners to sign) and must include:
1) It is a permanent procedure
2) Occasionally may fail
3) Post-tubal ligation syndrome

Female Sterilization
Method
Mechanical blockage of both Fallopian tubes to prevent sperm reaching & fertilizing the oocyte

Approach Complications
 Laparoscopy  Anesthetic problems
 Mini laparotomy  Laparoscopic injury to intra-abdominal organs during this procedure
 Hysteroscopy  Failure rate = 0.5% (1:200), (30% of pregnancy likely to be ectopic)
Technique Approach Features
Filshie clips Laparoscopy o Several types available
o Occasionally may not occlude whole tube
Fallope rings o Easy to apply
o Damages 2 – 3cm of tube, thereby making
subsequent reversal more difficult
Ligation Mini Laparotomy o Suitable for postpartum
o Relative higher failure rate
Electrocautery/ Laparoscopy o May damage surrounding structures
Diathermy Mini Laparotomy o Relatively higher late failure rate
Essure Hysteroscopy o Expanding metal springs placed into Fallopian
tubes proximally
Chemical Agents o Anti-Protozoa, Anti-Malarial, Anti-Lupus
(e.g. Quinacrine) Sclerosing Agent
Male Sterilization
Vasectomy Techniques
Division of the vas deferens on each side to prevent the release of sperm  Electrocautery/Diathermy
- Unipolar diathermy (common)
Advantages  Excision
Easier, Quicker, Cheaper, Under LA - Histological confirmation
 No-scalpel vasectomy
Disadvantages  Silicone plugs/Sclerosing agents
Takes 12 – 16 weeks to be effective
(Provide seminal analysis  Azoospermia)