Contraception: Objective at The End of This Lecture The 5 Year Student Should Be Able To
Contraception: Objective at The End of This Lecture The 5 Year Student Should Be Able To
د
المرحلة الخامسة
2019-2020
Contraception
OBJECTIVE
At the end of this lecture the 5th year student should be able to
1. Identify intrauterine contraceptive device.
2. Describe mode of action for each contraceptive method.
3. Describe how to select method of contraception
4. Identify contraindications,side effects of different types of
contraceptive method.
5. Describe the management of missed pill
Failure rate:
Are expressed as the number of pregnancies if 100 women were to use
the method for one year.
Failure rates for some methods are largely caused by poor use(user
failure) rather than an intrinsic failure of the method itself.method wich
prevent ovulation are usually highly effective because there is no egg
then fertilization simply can not occure.However,if ,for example,pills
are forgetting ,then breakthrough ovulation can occure & failure rates
are higher.Method which require no regular need for the user to
remember to do anything,for example an intrauterine device or
Implanon,are generally much more effective than methods which rely
on the user to do something regularly.
The effectiveness of contraceptive methods:
Contraindications
Contraception is generally extremely safe; some methods do have very
rare but serious risks. It is important to establish any factors in the
medical history that could contraindicate a particular method.
No method is contraindicated by age alone.
(WHO) criteria for contraceptive use:
category definition
1 No restriction for the use of the method
2 The advantages of using the method generally
outweigh the theoretical or proven risk
3 the theoretical or proven risks usually
outweigh the advantages of using the
methd,requires careful clinical judgment &
access to clinical services
4 Represent an unacceptable health risk if the
contraceptive method is used
Mode of action:
COC acts both centrally & peripherally.
1. Inhibition of ovulation:
Both oestrogen & progestogen suppress the release of pituitary follicle-
stimulating hormone (FSH) & lutenizing hormone (LH), which prevents
follicular development within the ovary & therefore ovulation.
2. Peripheral effects include making the endometrium atrophic &
hostile to implantation & altering cervical mucus to prevent sperm
ascending into the uterine cavity.
Formulation:
Oestrogen:
-Ethinyl estradiol (EE) in a daily dose of between 15 -35 µg.
Those containing lower dosage are associated with slightly poorer cycle
control.Those containing higher daily dosages ex: 50 µg EE are
prescribed in special situations.
Higher dosage of oestrogen(above 50µgEE) are strongly linked to
increased risks of both arterial & venous thrombosis.
-Anew combined preparation contains the natural oestrogen,estradiol
valerate,in place of synthetic EE.
Progestogens:
-Second generation pills: contain derivatives of norethindrone &
levonorgestrel.
-Third generation pills: include desogestrel,gestodene & norgestimate.
-pills containing the newer progestogens:drospirenone & dienogest
-combined preparation contains the potent anti-androgen cyproterone
acetate (Dianette),
Regimens:
-monophasic pills: are almost always used & contain standard daily
dosages of oestrogen and progestogen.
-biphasic,triphasic or quadriphasic preparations: have two, three or
four incremental variations in hormone dose ,more complicated, few
real advantages.
Most brands contain 21 pills, one pill to be taken daily,followed by a
7-day pill-free interval(the traditional 21/7 model) .
There are also some every day(ED) preparations that include seven
placebo pills that are taken instead of having a pill-free interval.
Other regimens include (24/4) & (84/7) & 365(where a pill is taken daily
without any breaks)
Contraindications:
Most of these relate to the side effects of sex steroid hormones on the
cardiovascular & hepatic systems.
Women should ideally discontinue COC at least two months before any
elective pelvic or leg surgery because of the risk of venous
thromboembolism.
Absolute contraindications for use of theCOC:
1. Breast feeding less than 6 weeks postpartum.
2. Smoking 15 cigarettes/day & age 35 or above.
3. Multiple risk factors for cardiovascular disease.
4. Hypertension: systolic pressure 160 or diastolic 100 mmHg
5. Hypertension with vascular disease.
6. Current or history of deep-vein thrombosis/pulmonary embolism.
7. Major surgery with prolonged immobilization.
8. Known thrombogenic mutations.
9. Current or history of ischaemic heart disease.
10. Current or history of stroke.
11. complicated valvular heart disease.
12. Migraine with aura.
13. Migraine without aura & age 35
14. Current breast cancer.
15. Diabetes for 20 years or with severe vascular disease or with severe
nephropathy,retinopathy or neuropathy,
16. Active viral hepatitis.
17. Severe cirrhosis.
18. Benign or malignant liver tumors.
-venous thromboembolism:
COC increases risk of VTE three to five- folds. Oestrogen (in COC,
pregnancy & with hormone replacement therapy) alters blood clotting
& coagulation in a way that induces a pro-thrombotic tendency. The
effect appears independent of dose of EE dose below 50µg but is
significantly increased with higher dosages above this.
The type of progestogen also affects the risk of VTE, with users of
COC containing third-generation progestogens being twice as likely to
sustain a VTE as those using older second generation preparations. The
absolute risk of an event with COC is very small but increased in the
presence of an inherited thrombophilia.Women with a significant
family history of VTE should be carefully assessed & tested for inherited
thrombophilias prior to being prescribed COC.
The risk of VTE is:
*5/100000 for normal population.
* 10 per 10, 0000 COCP users.
* 29–400 per 10,0000 in pregnant/postpartum.
Arterial disease:
Is much less common than VTE but more serious. The risk of myocardial
infarction & thrombotic stroke in young, healthy women using low-dose
COC is extremely small.
Cigarette smoking & high blood pressure will both increase the risk,&
any women who smokes must be advised to stop COC at the age of 35
years. Around 1% of women taking COC will become significantly
hypertensive & they should be advised to stop taking it.
Breast cancer:
There is a slight increase in the risk of developing breast cancer among
current COC users. This is not of great significance to young women, as
the background rate of breast cancer is very low at their age.
For women in her forties or one with a strong family history, the
rate of breast cancer is higher.
Effect of COC on breast cancer risk disappears ten years after stopping
COC.
Drug interactions:
This can occure with enzyme –inducing agents (anti-epileptic
drugs).Higher dose estrogen pill combinations of 50 µg EE may need to
be prescribed.
Some broad spectrum antibiotics can alter intestinal absorption of
COC & reduce its efficacy. Additional contraceptive measures should
therefore be recommended during antibiotic therapy & 1 week
thereafter.
Progestogen-only contraception:
Progestogen-only contraception avoids the risks & side effects of
oastrogen.
The current methods of progestogen-only contraception are:
1. progestogen-only pill, or mini-pill
2. Subdermal implant (Implanon)
3. Injectables (Depo-provera,Noristeral)
4. hormone-releasing intrauterine system (Mirena)
Injectable progestogens:
A.depot medroxyprogesterone acetate 150 mg (Depo-Provera/DMPA):
Each injection last for 12 weeks, it is highly effective & given by deep
intramuscular injection.
Most women who use it develop very light or absent menstruation.
Depo-Provera will improve premenstrual syndrome & can be used to
treat menstrual problems such as painful or heavy periods. It is very
useful for women who have difficulty remembering to take a pill
regularly.
Depo-Provera causes low estrogen levels & this is associated with loss
of bone mineral density & osteoporosis especially when used for long
term.
Particular side effects of Depo-Provera include:
1. Weight gain (2-3) kg in the first year of use.
2. Delay in return of fertility-it may take around six months longer to
conceive compared to a women who stops COC.
3. Persistently irregular periods, most women become amenorrhea.
It lasts for 3 years & thereafter can be easily removed & further
implant inserted if requested.
There is a rapid return of fertility when it is removed, but irregular
bleeding is very common & is the major reason for early
discontinuation also, healthcare professionals need special training for
Implanon insertion & removal.
Intrauterine contraception:
It is ideal for women who want a medium-to long-term method of
contraception independent of intercourse & were regular compliance is
not required.
Types:
Spermicides:
Either:gel,cream ,pessaries,foam.
They all contain the active ingredient nonoxynol-9 .
Spermicides are designed to be used with another barrier method to
make them more effective.
Female barrier:
Female diaphragm should all be used with spermicidal cream or gel.
Diaphragms are inserted immediately prior to intercourse & should be
removed not earlier than 6 hours later.
Female barriers offer protection against pelvic infection,but can
increase the risk of urinary tract infection and vaginal irritation.
Withdrawal-coitus interruptus :
This method does not require any medical advice.The penis is removed
from the vagina immediately before ejaculation takes place.
It is not particularly reliable as pre-ejaculatory secretions may contain
million of sperm & young men often find it hard to judge the timing of
withdrawl.
Emergency contraception:-EC
It is back-up method that is used after intercourse has taken place &
before implantation has occurred.
EC should be considered if
1. Unprotected intercourse has occurred
2. Failure of barrier method,ex burst condom
3. If hormonal contraception has been forgotten.
Types of EC :
1-Hormonal emergency contraceoption:
A/Levonorgestrel single dose 1.5 mg.It has to be used within 72 hours of
an episode of unprotected intercourse has occurred & the earlier it is
taken the more effective it is.
It will prevent around three-quarters of pregnancies.It involves
disruption of ovulation or corpus luteal function depending on the time
in the cycle when hormonal EC is taken.
Sterilization:
Permanent methods of contraception
1-female sterilization: mechanical blockage of both fallopian tubes to
prevent sperm reaching & fertilizing the oocyte.It can also be achieved
by hysterectomy or total removal of the fallopian tubes.
It is performed by laparoscopy or mini laparotomy under G.A.
Technique:clips,fallope
ring,ligation,electrocutery/diathermy,Essure,chemical agents
ex,quinacrine.
Complication:
-anaesthetic problems.
-damage intra-abdominal organs
-some women presented with abnormal uterine bleeding.
2-vasectomy:easier,cheaper,more effective than female sterilization,does
not require general anaesthetic
It involves the division of the vas deferens on each side to prevent the
release of sperm during ejaculation.
If two consecutive semen samples taken at 12 & 16 weeks are free of
sperm ,the vasectomy can be considered complete.an alternative form of
contraception must be used until that time.
Trenscervical sterilization :
Using a transcervical approach to reach the tubal ostia by placing either
mechanical devices or chemical compound
END…..