Contraception

Dr Bellington Vwalika
Obstetrician and
Gynaecologist-UTH
Honorary Lecturer -UNZA
 Definition

 Theprevention of an unwanted pregnancy

using a contraceptive which acts by
preventing fertilization of the ovum by
spermatozoa

2
 Measurement of Contraception

 Pearl Index

 Life table Analysis

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 Methods available

 Oral contraception  Withdrawal

 Injectables  Natural
 Intrauterine devices  Sterilization
 Implants
 Barrier

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 Factors affecting choice of method

Whether or not a  is easy to obtain

method:  is easy to use and
 is permanent or discontinue
reversible  has frequent or
 is effective undesirable side effects
 is inexpensive
 is perceived to be safe

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 Factors affecting choice cont’d

 can be used while  requires partner

b/feeding cooperation
 must be used each time
 protects against STIs the couple have sexual
intercourse

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 ‘Contraceptive Method Mix’

 Refersto the variety of contraceptives

available to clients through a family planning
programme

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 Combined oral contraceptives
(COCs)

 Consists of oestrogen (E) and progestin (P)

 Monophasic pills - same dose of E/P all through the
course
 Biphasic pills - fixed dose or E/P & more P in the last
14/7
 Triphasic pills - variable dose of E/P
 Sequential pills - fixed dose of E, No P for first 7/7
then P for 14/7

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 Mechanism of action
- COCs

 Prevents ovulation by inhibiting

gonadotrophin secretion via an effect on both
pituitary and hypothalamic centres
 The progestin suppresses LH secretion (&
thus prevents ovulation, while the
oestrogenic agent suppresses FSH secretion
(& thus prevents the selection and
emergence of a dominant follicle

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 Efficacy of COC

 Typical usage is associated with a 3.0%

failure rate during the first year of use

 Efficacydecreases significantly when the

oestrogen component is removed

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 Absolute contraindications to COC
use

 thrombophlebitis,  undiagnosed abnormal

thromboembolic vaginal bleeding
disorders, CVA,  known or suspected
coronary occlusion pregnancy
 markedly impaired liver  smokers over the age
function of 35 years
 known or suspected
breast cancer

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 Relative contraindications to COC
use

 Migraine headaches  H/O obstructive

 Hypertension jaundice in pregn
  Sickle cell disease or
H/O gestational
diabetes sickle C disease
  Diabetes mellitus
Elective surgery
  Gall bladder disease
Epilepsy

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 Clinical problems associated with
COCs

 Breakthrough bleeding  Ovarian cysts

 Amenorrhoea  Drugs that affect
 weight gain efficacy
  Migraine headaches
Acne

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 Non-Contraceptive Benefits of
OCs

These can broadly be grouped into two main

categories:
 Benefits that incidentally accrue when OC is
specifically utilized for contraception &;
 Benefits that result from the use of OCs to
treat problems or disorders

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 Non contraceptive incidental
benefits of OCs

 less PID
 effective contraception  less rheumatoid arthritis
 less endometrial cancer  increased bone density
 less ovarian cancer  ~ less endometriosis
 fewer ectopic pregns.  ~ less benign breast disease
 more regular menses  ~ fewer ovarian cysts

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 OC as treatment

 DUB  hormone therapy for

 dysmenorrhoea hypothalamic
 amenorrhoea
mittelschmerz
 control of bleeding
 endometriosis
 ~ functional ovarian
prophylaxis
 cysts
acne & hirsutism
 ~ premenstrual
syndrome

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 Pill taking

 Effective contraception is present during the

first cycle of pill use, provided the pills are
started no later than the 5th day of the cycle
and no pills are missed

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 Missed Pills

 If a woman misses 1 pill, she should take that

pill as soon as she remembers and take the
next pill as usual. No back-up is needed.
 If she misses 2 pills in the first two weeks,
she should take two pills on each of the next
two days, and back-up for the next 7 days

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 Missed pills cont’d

 If2 pills are missed in the third week, or if

more than 2 active pills are missed at any
time, another form of contraception should
be used as back-up immediately and for 7
days or start a new pack with back-up for 7
days

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 The Progestin-Only Pill (POP)
Minipill

 Theminipill contains a small dose of

progestational agent (25% of that in COC)
and must be taken daily, in a continuous
fashion

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 Mechanism of Action - POP

The contraceptive effect is more dependent

upon endometrial and cervical mucus effects,
since the gonadotrophins are not consistently
suppressed
 The endometrium involutes and becomes
hostile to implantation and the cervical
mucus becomes thick and impermeable

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 POP cont’d

 There are no significant metabolic effects

(lipid levels, CHO metabolism and
coagulation factors remain unchanged)
 There is an immediate return to fertility upon
discontinuation
 Failure rates range form 1.1 to 9.6% per 100
women in the first year of use

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 POP cont’d

Pill taking
 The minipill should be started on the first day
of menses and a back-up method must be
used for the first 7 days
 The pill should be taken at the same time of
the day
 If more than 3 hours late in taking a pill, a
back-up method should be used for 48 hours
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 Problems associated with POP

POP have unpredictable  20% total lack of cycles

effect on ovulation ranging from irregular
 40% of patients can bleeding to spotting and
expect to have normal amenorrhoea
ovulatory cycles  development of
 40% short irregular functional cysts
cycles  levonorgestrel minipill
may be associated with
acne

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 POP

There are two situations where excellent

efficacy is achieved:
 In lactating women, the contribution of the
minipill is combined with prolactin-induced
suppression of ovulation adding up to very
effective protection
 In women over age 40, reduced fecundity
adds to the minipill’s effects.
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 Implant contraception -
NORPLANT

 Progestin circulating at levels 1/4 to 1/10 th of

those in COC, prevents conception by
suppressing ovulation and thickening cervical
mucus to inhibit sperm penetration
 Side effects include changes in menstrual
patter, weight gain, headache, and effects on
mood

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 NORPLANT

 consists of 6 capsules  the capsules release ~

34mm in length, 2.4 80 micro grams of
mm outer diameter, levonorgestrel per 24
containing 36 mm hours during the first 6-
crystalline 12 months of use
levonorgestrel.  once inserted have an
 the 6 capsules contain effective life of 5 years
a total of 216 mg of
levonorgestrel which is
very stable
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 The mechanism of action

 Suppression at both the hypothalamic and

pituiatry LH surge necessary for ovulation
 The constant level of progestin has a marked
effect on the cervical mucus
 Suppression of the estradiol-induced cyclic
maturation of the endometrium and
eventually causes atrophy

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 Disadvantages of NORPLANT

 disruption of bleeding  implants can be visible

patterns in up to 80% of under the naked eye
users  does not protect
 implants must be against STI/HIV
inserted and removed  acne
in a surgical procedure  30% of pregnancies are
by trained personnel
ectopic

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 Absolute contraindications

 active thrombophlebitis  benign or malignant

or thromboemboilc liver tumours
phenomena  known or suspected
 undiagnosed genital breast cancer
bleeding
 acute liver disease

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 IMPLANON

A single implant 4 cm long contains 60 mg of

3-keto desogestrel
 The hormone is released at a rate of about
60 micro grams per day
 Is designed to be provide contraception for 2-
3 years
 Efficacy and side effects are similar to those
or NORPLANT
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 Jadelle

 Two rods containing 75mg LNG crystals embedded

in a coplolymer and encased in silastic tubing
 Rods are 43mm long and 2.5mm wide
 Lasts for 5 years
 Rods are easier and more convenient to insert and
remove
 Norplant and Jadelle are bioequivalent over 5 years
of use

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 Injectable Contraception:
Depo-Provera

 Comes as microcrystals, suspended in an

aqueous solution
 Correct dose is150 mg IM (gluteal or deltoid)
every 3 months
 Relies on higher peaks of progestin to inhibit
ovulation and thicken cervical mucus. The
progestin level is high enough to block the
LH surge
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 Depo-Provera
cont’d

 The injection should be given within the first

5 days of the current menstrual cycle,
otherwise a back-up method is necessary for
2 weeks
 The injection must be given deeply in muscle
by the Z-track technique and not massaged

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 Depo-Provera
Advantages

 easy to use, no daily or  free from eostrogen

coital acton required related problems
 safe no serious health  private use not
effects detectable
 effective as sterilization,  enhances lactation
IUCD & implant  has noncontraceptive
contraception benefits

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 Depo-Provera
Disadvantages

 irregular menstrual  can’t be removed

bleeding  return to fertility is
 breast tenderness delayed
 weight gain  regular injections
 depression required
 no STI/HIV protection

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 Depo-Provera
Absolute contraindications

 Pregnancy

 Unexplained genital bleeding

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 Intrauterine Contraception

Types of IUDS

 Unmedicated IUDs -Lippes Loop

 Copper IUDs - TCu-380A, Tcu-220C, Nova
T, Mulitload-375
 Hormone-releasing IUDs - Progestasert

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 IUDS
Mechanism of Action

 The mechanism of action is the production of

an intrauterine environment that is
spermicidal

 Ovulation is not affected nor is the IUD an

abortifacient

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 Efficacy of IUDS

 The actual failure rate in the first year is

approximately 3%, with a 10% expulsion
rate, and a 15% rate of removal, mainly for
bleeding and pain.
 The non medicated IUDs never have to be
replaced

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 Timing of IUD insertion

 An IUD can be safely inserted at any time

after delivery, abortion or during the
menstrual cycle

 The IUD can also be inserted at Caesarean

section

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 IUD Use
and Medical conditions

 a woman with a H/O  women at risk of

ectopic pregn can use a bacterial endocarditis
copper IUD or the should receive
Levonorgestrel IUD prophylactic antibiotics
 a progestin releasing at insertion & removal
IUD should be  current, recent, or
considered for women recurrent PID is a
with bleeding disorder contraindication for IUD
use

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 Pregnancy with IUD in situ

 Spontaneous abortion - 40-50%, IUDs should

be removed if pregnancy is diagnosed and the
strings are visible
 Septic abortion - there is no evidence that there
is an increased risk of septic abortion if pregn
occurs, other than with the Dalkon Shield
 Pre-term labour and birth - incidence is
increased 4-fold

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 Barrier methods

Have been the most widely used contraceptive

technique throughout recorded history.
 Spermicides - 21% failure rate
 Cervical cap - 18-28%
 Sponge - 18%
 Diaphragm - 18%
 Condom - 12%

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 Periodic abstinence

 Is keyed to the observation of naturally

occurring signs and symptoms of the fertile
phase of the menstrual cycle.
 It takes into account the viability of sperm in
the female reproductive tract and the life
span of the ovum

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 Methods of Periodic abstinence

 Rhythm of Calender method

 Cervical Mucus method

 Symptothermal method

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 Periodic abstinence

Periodic abstinence is associated with good

efficacy when used correctly and consistently
and the following rules are observed:
 No intercourse during mucus days
 No intercourse within 3days after peak
fecundity
 No intercourse during times of stress

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 Withdrawal

 Involves removal of the penis from the

vagina before ejaculation takes place
 1st year failure rate - 18%
 Some sperm may be released before
ejaculation
 Is a better method than using no method at
all

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 Lactational Amennorrhoea Method
(LAM)

 High concentrations of prolactin work at both

central and ovarian sites to produce
lactational amenorrhoea and anovulation

 Elevated levels of prolactin inhibit the

pulsatile secretion of GnRH

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 LAM

 Onlyamenorrhoeic women who

exclusively breastfeed at regular intervals,
including at nighttime, during the first 6
months have the contraceptive protection
equivalent to the provided by oral
contraception

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 LAM

 With menstruation or after 6 months, the risk

of ovulation increases
 Supplemental feeding increases the risk of
ovulation (and pregnancy) even in
amenorrheic women
 Total protection against pregnancy is
achieved by exclusively b/feeding for 10
weeks
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 B/feeding and Contraception

The rule of 3s
 In the presence of FULL b/feeding, a
contraceptive method should be used
beginning in the 3rd postpartum month
 With PARTIAL b/feeding or NO b/feeding, a
contraceptive method should begin during
the 3rd postpartum week

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 B/feeding and Contraception

 Oral contraception even in low doses

diminishes the quantity and quality of breast
milk

 Depo-provera does not affect breast feeding

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 B/feeding and Contraception
cont’d

 Periodic abstinence cannot be used with a

great deal of confidence
 Barrier methods are an excellent choice for
motivated couples
 IUDs can be inserted after vaginal or C/S

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 Female Sterilization

 Unipolar coagulation
 Postpartum tubal excision
 Silastic (Falope or Yoon) ring
 Interval tubal excision
 Bipolar coagulation
 Hulka-Clemens clip/Filshie clip

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 Advantages of female sterilization

 Very effective-failure one in 200

 Permanent
 Nothing to remember
 No interference with sex
 Increased enjoyment-no worries
 No effect on milk
 No health risks
 Can be done soon after birth

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 Disadvantages

 Painful for few days

 Uncommon complications of surgery
– Infection
– Internal infection and bleeding
– anaesthetic risks
– Death
– Ectopic
– Requires trained staff
– Reversal difficult and expensive
– No protection against STI
– No method of proving effectiveness

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 Male Sterilization

 Standard vasectomy

 “No scalpel” technique

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 Advantages of vasectomy

 Very effective-failure 1/700

 Permanent
 Nothing to remember after 20 ejaculations or
3 months
 No interference with sex
 Increased enjoyment
 No apparent longterm health risks

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  Easier to perform,less expensive
 Able to test for efectiveness at any time

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 disadvantages

 Complications of surgery
– Discomfort for 2-3 days
– Pain in scrotum
– Brief feeling of faintness
– Bleeding
– Blood clots in scrotum
 Requires someone trained
 Not immediately effective-unless after 20
ejaculations or 3/12

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  Reversal expensive
 No STI protection

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 Reversal of Sterilization

 Pregnancy rates correlate with the length of

remaining tube, a length of 4 cm or more is
optimal
 Pregnancy rates are lowest with
electrocoagulation, and reach 70-80% with clips,
rings and surgical methods such as the
Pomeroy
 About 2 per 1000 women will eventually
undergo tubal anastomosis
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 counselling

 Consider reason for request

 Age
 Permanet
 Irreversible
 Explain procedure
 Failure rate

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 Medical methods for the Male

 Hormonal contraception is inherently a

difficult physiological problem, because
unlike cyclic ovulation in the female,
spermatogenesis is continuous

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 Medical methods for the Male

 Sex steroids reduce testosterone synthesis

which leads to loss of libido and development
of female 2o sexual characteristics. Sperm
counts are not reduced adequately
 GnRH analogues also decrease endogenous
synthesis of testosterone, and supplemental
testosterone must be provided

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 Medical methods for the Male

 Gossypol a derivative of cotton seed oil,

effectively decreases sperm counts to
contraceptive levels, by incapacitating the sperm
producing cells
 The pills are taken daily for 2 months until sperm
are no longer observed in the ejaculate, and then
weekly
 Fertility returns to normal 3 months after
discontinuation
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 Emergency Contraception

 Emergency contraception methods can

prevent pregnancy after unprotected
intercourse, method failure or incorrect
method use
 Can help reduce unplanned pregnancies,
many of which result in unsafe abortion

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 Emergency contraception
methods

 Combined oral contraceptive pills

 Progestin only pills

 Intra uterine contraceptive device

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 Oral contraceptive pills

 Emergency contraceptive pills use the same

ingredients as regular contraceptives
 Should be initiated ideally within 3 days (72
hours) of unprotected intercourse
 Should be taken in two doses 12 hours apart

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 COC

 Eachof the two doses of COC should

contain at least 100 ug (0.10 mg) Ethinyl
Estradiol (EE) and 500 ug (0.50 mg)
Levonorgestrel

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 COC

PC-4, Eugoynon 50, Neogynon, Noral, Nordiol,

Ovidon, Ovral, Ovran

 Two tablets per dose: each tablet contains

50 ug EE & either 0.25mg or 0.50 mg
levonorgestrel

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 COC

LoFemenal, Microgynon 30, Nordette, Ovral L,

Rigevidon

 Four tablets per dose: each tablet contains

30 ug EE & either 0.15 mg or 0.30 mg
Levonorgestrel

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 POP

 Eachof the two doses of POP contraceptives

should contain at least 0.75 mg
Levonorgestrel

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 POP

 Ovrette - 20 tablets per dose, each tablet

contains 0.0375 mg Levonorgestrel
 Microlut, Microval, Norgestron - 25 tablets
per dose, each tablet contains 0.03mg
Levonorgestrel

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 IUCDs

 Copper T and others

 Insertionwithin 120 hours (five days) of

unprotected intercourse

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