CONTRACEPTION
DR. HANI MAHDI
Modified Sep. 2017
Pearl Index, also called the Pearl rate, is the most common
technique used in clinical trials for reporting the effectiveness of
a birth control method.(the failure rate of contraceptives is quoted
using the Pearl Index)
• Perfect use failure rates reflect pregnancies that occurred with
individuals even though they always use their contraception correctly
and consistently.
• Typical use failure rates: These rates apply to folks who became
pregnant while not always using their contraception correctly and/or
consistently.
• Failure rate per hundred women- years of exposure (HWY)
Contracepive prevelance in developing
world
Percentage using
Region
1960-1965 1985-1990
East Asia
13 70
South Asia 40
7
Africa
5 17
Latin America
14 60
All developing countries
9 51
Temporary methods
•Natural regulation of fertility
•Barrier methods,
•Hormonal contraception
•Intra uterine contraceptive devices
•Emergency (Post coital ) contraception
Permanent methods
•Sterilization :
Female sterilization
Male sterilization: Vasectomy
Non Hormonal
•Barrier methods
•Intra uterine contraceptive devices
•Natural regulation of fertility
•Sterilization
HORMONAL
• STEROID CONTRACEPTION
Natural regulation of fertility
1-Natural family planning techniques
( Fertility Awareness Methods )
2-Contraceptive effect of breast feeding
( Lactational Amenorrhea Method)
Natural family planning techniques
OR/ ( Fertility Awareness Methods )
The calendar method
• The calendar method is based on 3 assumptions
as follows:
• (1) A human ovum is capable of fertilization only
for approximately 24 hours after ovulation,
• (2) spermatozoa can retain their fertilizing ability
for only 72 hours after coitus, and
• (3) ovulation usually occurs 12-16 days before
the onset of the subsequent menses
Chances of Pregnancy by Day of Intercourse
day zero is ovulation
-5 -4 -3 -2 -1 0 1 2 3
0% 11% 15% 20% 26% 15% 9% 5% 0%
For the calendar method (Ogina-Knaves method)
fertile time
Subtract 18 from the shortest cycle & 11 from the
longest cycle.
e.g : shortest cycle is 26 days & longest cycle is 34 days,
abstain from sexual relations from
Day 8 (26-18=8) through Day 23 (34-11=23).
Basal Body Temperature Method
(BBT)
BBT
When to take temperature?
Every morning before getting out of
bed & before any kind of activity
(talking, eating, drinking, smoking , or
sexual activity).
BBT
Fertile days are over when
BBT 0.2 to 0,5C for three full
days.
Cervical mucus method
• As the fertile time approaches, the mucus
increases in amount, becomes clearer in
color, wetter, stretchy, and slippery
After the fertile time, mucus usually
becomes sticky and pasty, decreased in
amount.
Or no mucus .
SYMPATHOTHERMAL METHOD
• The symptothermal method predicts the first day of
abstinence by using either the calendar method or
the first day mucus is detected, whichever is noted
first. The end of the fertile period is predicted by
measuring basal body temperature
• Efficacy
• The failure rate in typical use is estimated to be
approximately 25%.
Standard days method
For women with menstrual cycles
between
26 & 32 days.
Avoiding unprotected sexual
intercourse on days 8 through 19
WhatMethods
are fertility awareness
for planning methods?
or avoiding pregnancy by
observation of the natural signs and symptoms of the
fertile and infertile phases of menstrual cycle
PERIODIC ABSTINENCE
• Coitus interruptus
• Efficacy
• The failure rate is estimated to be
approximately 4% in the first year of
perfect use.
• In typical use, the rate is approximately
19%- 25% during the first year of use.
Lactational amenorrhea
•Efficacy
•The perfect-use failure rate within the
first 6 months is 0.5%. The typical-use
failure rate within the first 6 months is
2%.
•Advantages and disadvantages
BARRIER METHODS
A- SPERMICIDES
• Effectiveness:
• The perfect-use failure rate within the first year is 6%.
The typical-use failure rate within the first year is 26%.
• Types : creams, jellies, foams ,tablets and
suppositories.
• Composition. Nonoxynol 9 or octoxynol which disrupts
the integrity of sperm membrane
B- CONDOMS
• Condoms are made of latex which
can be damaged by oil-based spermicidal agents;
therefore, water-based spermicides should be used.
• Latex condoms prevent sexually transmitted diseases
(STD) such as HIV, but are less protective against STD
transmitted from skin-to-skin contact such as human
papilloma virus and herpes virus.
CONDOMS
• Advantages • Disadvantages
1. cheaper with no contraindications 1. May accidentally break or
2. no side effects slip off during coitus
3. easy to carry, simple to use and disposable 2. Inadequate sexual pleasure
4. protection against sexually transmitted 3. Allergic reaction (Latex)
diseases, e.g. gonorrhea, chlamydia and HIV 4. to discard after one coital
5. protection against pelvic inflammatory act
diseases 5. failure rate — 15%
6. reduces the incidence of tubal infertility and
ectopic pregnancy
7. protection against cervical cell
abnormalities
8. useful where the coital act is infrequent and
irregular
C - DIAPHRAGMS
• Effectiveness
• The typical-use failure rate within the first year is estimated to
be 20%.
• Types – Arcing spring, coil spring, flat spring
• Advantages and disadvantages
• The diaphragm does not entail hormonal usage
• Prolonged use may increase the risk of urinary tract infections.
• Possible risk of toxic shock syndrome (TSS).
Long-acting reversible
contraception (LARC)
LARC have been defined in the UK as a method that
requires administration less than once per month
INTRAUTERINE DEVICES
• Types of IUCDs:
• Lippes loop,
• Copper –bearing devices: copperT380 T-
shaped)
• Progesterone-releasing IUD Progestasert,
Mirena with levonorgestrel ).
Copper carrying devices
• Copper wire of surface area 200 to 250 mm is
wrapped round the vertical stem of a polypropylene
frame.
• Are reported to exert a better contraceptive effect,
with fewer side effects than inert devices.
• It is estimated that about 50 μg of copper is eluted
daily in the uterus.
• Copper T 380A has a lifespan of 10 years.
Progesterone releasing devices
• Mirena contains 52 mg LNG, eluting 20 μg daily. It can be
retained for 5 years, with a failure rate of 0.1 to 0.4 per
100 woman years.
• The hormone released in the uterus forms a thick plug of
mucus at the cervical os which prevents penetration by the
sperms and thus exerts an added contraceptive effect.
• Menstrual problems like menorrhagia and dysmenorrhoea
noticed with Copper T are less with this device (40%
reduction).
Mechanism of action
• The major actions of IUD’s is contraceptive and not abortifacient
• The presence of a foreign body in the uterine cavity renders the migration
of spermatozoa difficult.
• A foreign body within the uterus provokes uterine contractility through
prostaglandin release and increases the tubal peristalsis so that the
fertilized egg is propelled down the fallopian tube more rapidly than in
normal and it reaches the uterine cavity before the development of
chorionic villi and thus is unable to implant. (Increase PG synthesis)
• The intense inflammatory response induced in the uterus by IUD leads to
lysosomal activation and other inflammatory actions that are
spermicidal.(Evoke sterile inflammatoy response)
Mechanism of action cont.
• Copper T elutes copper which brings about certain enzymatic
and metabolic changes in the endometrial tissue which are
inimical to the implantation of the fertilized ovum.(Produce
asynchronous development of the endometrium).
• Progestogen-carrying device causes alteration in the cervical
mucus which prevents penetration of sperm, in addition to
its local action. It also causes endometrial atrophy. It
prevents ovulation in about 40%.
Complications of IUCD
• Immediate • Late
• Difficulty in insertion • PID-2 to 5%. IUCD does not
• Vasovagal attack prevent transmission of HIV.
• Uterine cramps • Pregnancy-1 to 3 per 100
woman years (failure rate)
• Early
• Ectopic pregnancy
• Expulsion (2 to 5%)
• Perforation
• Perforation (1 to 2%)
• Menorrhagia
• Spotting, menorrhagia (2 to 10%)
• Dysmenorrhoea
• Dysmenorrhoea (2 to 10%)
• Vaginal infection
• Actinomycosis
Uses of IUCD
• As a contraceptive
• Postcoital contraception (emergency contraception)
• Following excision of uterine septum, Asherman's syndrome
• Hormonal IUCD (Mirena) in menorrhagia and
dysmenorrhoea, and hormonal replacement therapy in
menopausal women
• In a woman on tamoxifen for breast cancer, it can be used to
counteract endometrial hyperplasia.
Patient selection
IUCDs are a good choice for the following groups of women:
• Low risk of STD
• Multiparous woman
• Monogamous relationship
• Desirous of long-term reversible method of contraception
• Desirous of permanent sterilization
• Unhappy or unreliable users of oral contraception or barrier
contraception.
IUD (cu devices and Hormone releasing IUDS)
Contraindications
• Absolute • Relative
• Active pelvic infection • H/O PID
• Pregnancy • H/O ectopic pregnancy
• Uterine anomalies or
• Cervical or uterine leiomyomata
malignancy or unresolved • Vulvar heart disease
Pap smear.
• Impaired immunity
• Heavy menstrual bleeding and
dysmenorrhea
• Concern for furture fertility
WHO Contraindications to IUC use
From WHO 2015
Effects of LARC
• The LNG-IUS also offers non-contraceptive benefits. It
decreases menstruation and has a protective effect on pelvic
inflammatory disease (PID).
• Two randomized trials have demonstrated a statistically
significant reduction in the recurrence of painful periods in
women with endometriosis who used LNG-IUS compared
with those who did not
• Copper IUDs can cause anemia, whereas the LNG-IUS has the
added benefit of treating anemia
Effects of LARC on Bleeding and Pain
Think T or F
• With regards to the intrauterine contraceptive
device:
• it should be removed when a diagnosis of pelvic
inflammatory disease (PID) is made.
• in women diagnosed with PID, there is no need
for antibiotic use following its removal.
IUCD and PID
• The World Health Organisation expert working group on
recommendations for contraceptive use concluded that
there was no additional benefit to be gained by removing an
IUCD in a woman diagnosed with mild to moderate PID who
had been commenced on antibiotics.
• Indeed, if the woman wanted it removed, this should take
place only after antibiotics have been started.
• It would, however, be sensible to remove if, at review, there
was no clinical improvement or indeed deterioration.
HORMONAL CONTRACEPTIVES
• Implants
• The US Food and Drug Administration (FDA) approved the
contraceptive use of levonorgestrel implants (Norplant) in
1990. This method consists of 6 silicone rubber rods, each
measuring 34 mm long and 2.4 mm in diameter and each
containing 36 mg of levonorgestrel. The implant releases
approximately 80 mcg of levonorgestrel per 24 hours during
the first year of use
IMPLANTS
• The mechanism of action is a combination of suppression of the LH surge,
suppression of ovulation, development of viscous and scant cervical mucus
to deter sperm penetration, and prevention of endometrial growth and
development.
• Insertion: The capsule is inserted subdermally, in the inner aspect of the
nondominant arm, 6–8 cm above the elbow fold. It is inserted between
biceps and triceps muscles.
• Advantages and disadvantage:
• Efficacy of implanon is extremely high with Pearl indices of 0.05. This safe
and effective method is considered as ‘reversible sterilization’.
• Drawbacks:
Frequent irregular menstrual bleeding, spotting and amenorrhea are
common. Difficulty in removal is felt occasionally.
Injectable depomedroxyprogesterone
acetate
• (DMPA) is a suspension of microcrystals of a
synthetic progestin that is injected intramuscularly .
• DMPA acts by the inhibition of ovulation with the
suppression of follicle-stimulating hormone (FSH)
and LH levels and eliminates the LH surge. This
results in a relative hypoestrogenic state.
• Efficacy
• DMPA is an extremely effective contraceptive option.
Within the first year of use, the failure rate is 0.3%.
DMPA
• Advantages • Disadvantages
• DMPA does not produce the • Disruption of the menstrual
serious adverse effects of cycle to eventual
estrogen, such as amenorrhea occurs in 50%
thromboembolism. of women within the first
• Diminished anemia occurs. year.
• Dysmenorrhea is decreased. • Persistent irregular bleeding
• The risks of endometrial • Delay in fertility after
and ovarian cancer are discontinuation of DMPA,
decreased . • Weight gain
Injectable medroxyprogesterone acetate
and estradiol combination
• It consists of a single injection of
medroxyprogesterone acetate and estradiol
combination (MPA/EC) containing
medroxyprogesterone and estradiol cypionate.
• It is administered monthly
• Efficacy
• One-year failure rates of less than 1% were reported
from the clinical trials .
ADVANTAGES
• Regular menses occur, with an average cycle of 28
days.
• Dysmenorrhea and menorrhagia decrease.
• . Return to fertility is 53% and 83% within 6 months
and 8 months, respectively.
• Disadvantages include irregular spotting, weight
gain, possible decrease in libido, and mild
depression.
Progestin-only Ocs (MINIPILLS)
• Candidates for use include women who are
breastfeeding and women with contraindications
to estrogen use.
• Two formulations are available:
• One formulation contains 75 mcg of desogestrel
• The other has 350 mcg of norethindrone.
MINIPILLS
• Mechanisms of action include
• (1) suppression of ovulation (not uniformly in all cycles);
• (2) a variable dampening effect on the midcycle peaks of LH
and FSH;
• (3) an increase in cervical mucus viscosity by a reduction in its
volume and an alteration of its structure;
• (4) a reduction in the number and size of endometrial glands,
leading to an atrophic endometrium not suitable for ovum
implantation; and
• (5) a reduction in cilia motility in the fallopian tube, thus
slowing the rate of ovum transport.
MINIPILLS cont.
• Efficacy
• Failure rates with typical use are estimated to be 7% in the first year of use.
• Advantages:
• decreased dysmenorrhea,
• decreased menstrual blood loss,
• decreased premenstrual syndrome symptoms. Fertility is immediately
reestablished after the cessation of progestin-only OCs.
• Disadvantages
• The most significant disadvantage is the continuous need for compliance with usage
• Contraindications
Breast Cancer, active liver disease, benign and malignant liver tumors (except
nodular hyperplasia).
Strong Contraindications to Progestin-Only
Methods
Combination OCs
• Ethinyl estradiol is used in all preparations containing 35
mcg or less of estrogen
• The progestin component consists of norethindrone,
levonorgestrel, norgestrel, norethindrone acetate,
ethynodiol diacetate, norgestimate, and desogestrel. The
most recent addition to the progestin group is the addition
of drospirenone, found in Yasmin birth control pills.
• The other major new development is the reduction in the
dosage of ethinyl estradiol to 20 mcg
Combination OCs
• Monophasic OCs have a constant dose of
both estrogen and progestin .
• Biphasic 10/11 or 7/14
• Triphasic 6/5/10 (triovlar )
• 6 tab EE 30mcg+50mcg Norgestril
• 5 tab EE40mcg+75mcg Norgestril
• 10 tab EE30mcg+125mcg norgestril
Mechanism of action
• The combined oral pill suppresses pituitary hormones, FSH
and LH, peak and through their suppression prevents
ovulation.
• At the same time, progestogen causes atrophic changes in the
endometrium and prevents nidation.
• Progestogen also acts on the cervical mucus making it thick
and tenacious and impenetrable by sperms.
• It also increases the tubal motility, so the fertilized egg
reaches the uterine cavity before the endometrium is
receptive for implantation.
COCs
• Multiple methods may be used to start COCs:
• “Quick start” method—starting on the day of
counseling
• “Sunday start” method—starting on the 1st
Sunday after starting menses
• “Day one start” method—starting the pills on
the first day of menses
• A week of backup contraception is
recommended after all initiation methods
Advantages
• OCs are used as treatment for menstrual irregularity
• In the prevention of ovulation, OCs can reduce and sometimes eliminate
mittelschmerz.
• Women with anemia secondary to menorrhagia increase their iron stores.
• Women can manipulate the cycle to avoid menses during certain events,
by extending the number intake days of hormonally active pills.
• OCs prevent benign conditions, such as benign breast disease, pelvic
inflammatory disease (PID), and functional cysts.
• Functional cysts are reduced by the suppression of stimulation of the
ovaries by FSH and LH.
• Ectopic pregnancies are prevented by the cessation of ovulation.
• OCs are noted to prevent epithelial ovarian and endometrial
carcinoma(40% and 50% respectively).
Disadvantages
• Adverse effects include nausea, breast tenderness, weight gain,
breakthrough bleeding, amenorrhea, headaches, depression and
anxiety.
• Metabolic effects and safety
• Venous thrombosis: The estrogen component of OCs has the
capability of activating the blood clotting mechanism
• Hypertension is believed to be secondary to an estrogen-induced
increase in renin substrate in susceptible individuals .
• Atherogenesis and stroke If a woman’s triglycerides are above 350
mg/dL or in patients with familial hypertriglyceridemia, CHCs
should be avoided because they may precipitate pancreatitis
and/or adversely affect the patient’s risk for cardiovascular disease.
Cancer : breast ?? Cervical ??
Cervical Cancer
• OCs alone do not increase the risk of cervical cancer.
• However, there is strong evidence that recent use of CHC is
associated with increased risk of human papillomavirus
(HPV) infection independent of sexual behavior and cervical
abnormalities. Among HPV-infected women, those who used
OCs for 5 to 9 years have approximately three times the
incidence of invasive cancer, and those who used them for
10 years or longer have approximately four times the risk.
• The mechanism is probably related to CHC affecting host
response, making her less likely to clear HPV infection rather
than increasing the risk of HPV acquisition.
CONTRAINDICATIONS
• Cerebrovascular disease or coronary artery disease;
• A history of deep vein thrombosis, pulmonary embolism, or
congestive heart failure;
• Untreated hypertension;
• Diabetes with vascular complications (Diabetic neuropathy
retinopathy, neuropathy, or other vascular disease) ;
• Estrogen-dependent neoplasia; breast cancer;
• Undiagnosed abnormal vaginal bleeding;
• Known or suspected pregnancy;
• Active liver disease;
• Symptomatic gallbladder disease and age older than 35 years and
cigarette smoking.
Strong
Contraindications
to Combined
Hormonal
Contraceptive
Use
Migraine and Headache
• Patients with a history of migraine headaches should use CHCs
cautiously. Some patients will note an improvement, whereas some
will notice no change; however, approximately 50% of patients will
notice a worsening of their condition, especially during the hormone-
free interval.
• One commonly accepted contraindication to the use of CHCs is a
history of classic migraine (migraine with focal neurologic symptoms
or aura lasting 5 to 60 minutes) due to an increased potential for
stroke.
• It should be noted that women with a history of migraines have a
two- to three-fold increased risk of ischemic stroke, regardless of CHC
use.
Think True or False
•The oral contraceptive pill
•A. increases the rate of chlamydial cervicitis.
•B. reduces the risk of symptomatic PID.
•C. reduces the clinical severity of PID.
Oral contraceptive pills and PID
• The association between the oral contraceptive pill and
PID is poorly understood.
• It was thought that it may exert a protective effect
against the ascent of infection by progesterone-induced
changes in the cervical mucus barrier and endometrial
suppression or a direct steroid effect reducing immune-
related damage to the tubal mucosa.
• However, it may just reduce the prevalence of
symptomatic infection and not alter the true prevalence
of PID
Medical eligibility criteria (modified from WHO)
Female sterilization
• Sterilization can be performed surgically in the postpartum
period with a small transverse infraumbilical incision or during
the interval period. Sterilization during the interval period can be
performed with laparoscopy or laparotomy.
• The methods of fallopian tube sterilization include:
• Occlusion with Falope ring
• Clips, or bands
• Segmental destruction with electrocoagulation
• Suture ligation with partial salpingectomy: Pomeroy ,Irving ,Cook.
• Essure microinserts
Female sterilization cont.
• Advantages:
• Sterilization is highly effective with no long-term side effects.
• Tubal ligation decreases the risk of ovarian cancer. This may be
due to decreased risk of ascending carcinogens from the
fallopian tubes.
• Disadvantages:
• Sterilization requires anesthesia.
• Abdominal approaches should consider factors such as prior
abdominal surgery and pelvic adhesive disease before being
performed.
• Tubal ligation offers no protection against sexually transmitted
diseases (STDs).
Hysteroscopic Tubal Sterilization (Essure Micro Insert)
• Essure is an irreversible form of tubal occlusion that can be performed in
the operating room or in the office, taking <1 hr.
• Hysteroscopically, a 4 cm × 1 cm spring-loaded stainless steel and nickel
titanium coated expanding coil is released bilaterally into the tubal ostia.
• Tubal blockage occurs by tissue growth and scarring over time.
• A hysterosalpingogram is required 3 months after the procedure to
confirm tubal occlusion.
• Failure rate from clinical trial research is <1%.
• This method may be preferred over tubal ligation in women who are obese
or who have had prior abdominal operations resulting in adhesions.
• Expulsion of one or both devices occurs 3% of the time, and there is a 14%
chance of inability to place one or both inserts.
"micro-insert" or "Essure®"
Male sterilization
• Vasectomy involves incision of the scrotal sac, transection
of the vas deferens, and occlusion of both severed .
• Efficacy
• The failure rate is approximately 0.1%.
• This method is highly effective, has no long-term side
effects, is less expensive, and has fewer complications than
tubal ligation.
• Vasectomy requires a surgical procedure, is permanent,
offers no protection against STDs, and is not immediately
effective.
Emergency contraceptives
• Yuzpe method in use since the 1970s, it consists of the oral
administration of 2 doses of 100 µg ethinyl estradiol (EE)
and 500 µg levonorgestrel 12 hours apart.
• Plan B, consisting of two tablets each containing 750 μg of
levonorgestrel, was approved by the FDA in 1999 to be taken
as one pill every 12 hours up to 72 hours after unprotected
coitus.
• The two tablets (1.50 mg) can be taken as a single dose also.
• Ulipristal acetate 30 mg po
• Copper T380 intrauterine device insertion within 5 days
Emergency contraceptives
Progestin-only emergency contraception.
•LNG appears effective up to 96 hours after
unprotected sex and ulipristal acetate for up
to 120 hours.
• The primary mechanism by which emergency
contraception is thought to work is by delay or
inhibition of ovulation.
• There are no absolute contraindications to
progestin-only emergency contraception.
Percentage of Women Experiencing an Unintended Pregnancy Within the First Year of Use of Contraception
From World Health Organization
