o&g update course 2012 hospital segamat

1. Dr Junita Aris
Klinik Kesihatan Segamat
Family Planning methods
(Contraception)

2. Intentional prevention of conception or
impregnation through the use of various
devices, agents, drugs, sexual practices, or
surgical procedures.
Contraception

3. CATEGORIES CLASSIFICATION
1 A condition for which there is no
restriction for the use of contraceptive
method
2 A condition where the advantages of
using the method generally out weight
the theoretical or proven risks
3 A condition where the theoretical or
proven risks usually out weight the
advantages of using the method
4 A condition which represent an
unacceptable health risk of the
contraceptive method is used
Contraception-WHO MEC

4. CATEGORY WITH CLINICAL
JUDGEMENT
WITH LIMITED CLINICAL
JUDGEMENT
1 USE THE METHOD IN ANY
CIRCUMSTANCES
YES - USE THE METHOD
2 CAREFULLY USE THE
METHOD
YES - USE THE METHOD
3 NOT USUALLY
RECOMMENDED UNLESS
NO OTHER MORE
APPROPRIATE METHOD
AVAILABLE
NO – DO NOT USED THE
METHOD
4 METHOD NOT TO USED NO – DO NOT USED THE
METHOD
Contraception-WHO MEC

5. Barrier method
• Male condom
• Female condom
• Diaphragm
• Cervical cap
Contraception

6. Hormonal
Oral
• POP
• COCP
Injectables
• Depo provera
• Noristerat
Device
• Norplant
• Implanon
• IUCD
copper
LNG (levonorgestrel)
Contraception

7. Evra patch
Nuva ring
Contraception

8. Sterilization
Female –Tubal Ligation
Male -vasectomy
Contraception

9. Barrier method

10. Male condom
Typical use 15%
Perfect use 2%

11. Male condom

12. Male condom

13. Male condom

14. What are the chances of getting pregnant while
using a female condom?T
Typical use: 21 %
Perfect use: 5 %
Female Condom

15. • Female diaphragm
• Cervical cap
What are the chances of
getting pregnant
Typical use: 20 %
Perfect use: 9 %
Typical use: 10 %
Perfect use : 4%
Female Condom

16. Male Condom Female condom
Rolled on the mans penis
Fit on the erect penis
Inserted into the woman’s vagina
Made of latex FC2 is made of nitrile and FC is made of
polyurethane
Lubricant:
Can include spermicide
Can be water-based only; cannot be oil-
based
Located on the outside of condom
Lubricant:
Can include spermicide
Can be water-based or oil-based
Located on the inside and outside of
condom
Condom must be put on an erect penis Can be inserted prior to sexual
intercourse, not dependent on erect
penis

17. Male condom Female condom
Must be removed immediately after
ejaculation
Does not need to be removed
immediately after ejaculation
Covers most of the penis and protects the
woman’s internal genitalia.
Covers both the woman’s internal and
external genitalia and the base of the
penis, which provides broader protection.
Latex condoms can decay if not stored
properly
Is not susceptible to deterioration from
temperature or humidity.
Recommended as one time use product. recommended for one time use

18. Benefits
• Help protect against STIs, including HIV
• No hormonal side effects
Side effect
Allergic reaction to latex
Condom

19. HORMONAL

20. Combined oral contraceptive (COC)

21. - contains two steroid
hormones-
estrogen&progesterone
- Estrogen component of
most modern COC is
ethinyloestradiol(EE) in
the dose range of 20-
50microgram
- Progesterone component
vary in different
preparations
Combined oral contraceptive (COC)

22. • Progestogen Component
– second generation(e.g.norethisterone and
levonorgestrel)
– third generation(desogestrel and gestodene)
• Third generation have a higher affinity for the
progesterone receptor and a lower affinity for
androgen receptor- LESS SIDE EFFECT
Combined oral contraceptive

23. • In theory, they confer greater efficacy with
fewer androgenic side effects
• Also have fewer effects on carbohydrate and
lipid metabolism than second generation
compounds
• However evidence has shown it has not
resulted in a reduction in the risk of arterial
wall disease or AMI
Combined oral contraceptive

24. • Monophasic-all 21 active pills contain same
amount of oestrogen and progesterone
• Biphasic-21 active pills contain 2 different
Oes/P combinations
• Triphasic-21 active pills containing 3 different
Oes/P combinations
Combined oral contraceptive-types

25. Mechanism of action
• Oestrogen component inhibits pituitary FSH
secretion-suppresses follicle growth; progesterone
component inhibits the LH surge  inhibits ovulation
• Cervical mucus becomes scanty and viscous-inhibits
sperm transport
• The endometrium becomes atrophic and
unreceptive to implantation
• Possibly direct effects on the fallopian tubes
impairing sperm migration and ovum transport
Combined oral contraceptive

26. • Effectiveness
– Depends on user
– < 1 pregnancy per 100 woman used over first year
(3 per 1000 woman) if used without mistake
– Failure is greatest when woman starts a new pill
pack 3 or more days later
• Convenience
• Reversibility
– No delayed returning of fertility after COC stopped
COC - contraceptive benefits

27. • Reduction of most menstrual cycle disorders:
less heavy bleeding, therefore less anaemia,
and less dysmenorrhoea
• Regular bleeding, the timing of which can be
controlled: fewer symptoms of premenstrual
tension overall; no ovulation pain
COC - non contraceptive benefits

28. • Fewer functional ovarian cysts
• Fewer extra uterine pregnancies
• Reduction in pelvic inflammatory ds
• Fewer symptomatic fibroid
• Reduced risk of cancers of ovary and
endometrium
COC - non contraceptive benefits

29. • Weight gain: pills containing levonorgestrel(LNG)
but not desogestrel or gestodene
• Carbohydrate metabolism: minor effects on
insulin secretion
• Lipid metabolism: the effect on the ratios of total
and LDL cholesterol to HDL cholesterol depends
on the relative doses of Oestrogen/Progestrogen
and type of progesterone used
COC - limitation/side effects

30. • Venous disease:
EE causes an alteration in clotting factors ,
promoting coagulation and increasing the
relative risk of VTE in current COC users by 3-4
fold compared to women not taking COC
• COC containing 3rd generation progestogens
(desogestrel and gestodene) possibly carry a
small additional risk of VTE compared to that of
2nd generation
COC - limitation/side effects

31. Arterial disease
• relative risk of MI and haemorrhagic stroke in
current users with hypertension or who smoke is
increased more than in non smoking users
without hypertension, who are at no greater risk
than non users
• Relative risk of ischaemic stroke in normotensive
current users who do not smoke is increased
about 1.5-fold compared to non users.
COC - limitation/side effects

32. • Ideally the COCP should
be started on the first
day of menstrual
bleeding, but can be
started up to day 5
without the need for
extra protection.
• It can be started at any
other time IF THE
PATIENT IS SURE SHE IS
NOT PREGNANT, but
additional protection
e.g. condoms will be
needed for the first 7
days.
COC - when to start

33. Past or present circulatory
disease
• Proven past arterial or
venous thrombosis
• IHD
• Severe multiple risk
factors for venous or
arterial disease
• Focal migraine
• TIA
• Artherogenic lipid
disorders
Disease of the liver
• Active liver ds (i.e.with
abnormal liver function
test)
• Liver adenoma or
carcinoma
• Gallstones
• Acute hepatic porphyrias
COC-Absolute Contraindication
(WHO 4)

34. Others
• Pregnancy
• Undiagnosed genital tract bleeding
• Oestrogen dependent neoplasms,e.g breast
cancer
COC-Absolute Contraindication
(WHO 4)

35. • Undiagnosed oligomenorrhoea
• Cigarette smoking above age 35
• Diabetes
• Non focal migraine
• Sickle cell disease
• Inflammatory bowel ds
• Obesity(if ass with other risk factors)
COC-Relative Contraindication
(WHO 2 & 3)

36. • Controlled by the woman
• Stopped at any time without health provider help
• Do not interfere with sexual activity
• Safe and suitable for nearly all woman
• At any age including adolescent, woman age > 40
• Following a miscarriage
• Without pelvic examination
• Without cervical cancer screening
Women like COC

37. Drug interactions
- AntiTB( Rifampicin)
- Antiepileptic
(barbiturates,phenytoin
carbamazepine)
- Antibiotic
(doxcycline, ampicillin)
COC-Drug Interactions

39. • Progestin-only pills (POPs)
• Depo-provera
• Norplant
• Implanon
PROGESTOGEN
ONLY CONTRACEPTIVES

40. Mechanisms of action
• Suppress ovulation
• Reduce sperm transport in upper genital tract
(fallopian tubes)
• Thicken cervical mucus
preventing sperm penetration
PROGESTOGEN
ONLY PILLS (POPs)

41. )
• Effective when taken at the same time daily
• Immediately effective (<24 hours)
• Do not interfere with intercourse
• Do not affect breast feeding
• Immediate return to fertility when stopped
• If BF + LAM – near 100% effective
• If not BF – 99.5% effective
POPs-Contraceptive benefits

42. • Few side effects
• Convenient and easy to use
• Client can stop use
• Can be provided by trained non-medical staff
• Contain no oestrogen
POPs-Contraceptive benefits

43. • May decrease menstrual cramps
• May decrease menstrual bleeding
• May improve anaemia
• Protect against endometrial cancer
• Decrease benign breast disease
• Decrease ectopic pregnancy
• Protect against some causes of PID
POPs-Non Contraceptive benefits

44. • Changes in menstrual bleeding pattern
• Some gain weight or loss may occur
• User dependent
• Must be taken at the same time daily
• Resupply must available
• Drugs interaction – epilepsy, TB
• Do not protect against STDs
POPs-Limitations

45. • POPs are not recommended unless other
methods are not available or acceptable if
woman ;
– Has unexplained vaginal bleeding (if suspected
serious problem)
– Has breast cancer (current / with h/o )
– Is jaundiced (active, sx)
POPs-condition requiring precaution
(WHO Class 3)

46. • Is taking drugs for epilepsy
(phenytoin/barbiturates) or TB (rifampicin)
• Has severe cirrhosis
• Has liver tumours
• Has had a stroke
• Has IHD
POPs-condition requiring precaution
(WHO Class 3)

47. • Blood pressure (<180/110)
• Uncomplicated DM ( < 20 yrs illness)
• Preeclampsia ( h/o)
• Smoking (any age / amount )
• Surgery (± long bed rest)
• Thromboembolic disorders
• Valvular heart disease (± symptomatic)
POPs-No Restriction

48. • Day 1 menstrual cycle
• Any time when sure pt is not pregnant
• Post partum
– After 6/12 if using LAM
– After 6/52 if breastfeeding but not using LAM
– Immediately or within 6 weeks if not
breastfeeding
• Post abortion (immediately)
POPs-When to start

49. • Amenorrhoea (absence of PV bleeding or
spotting)
• Bleeding or spotting
• Heavy or prolonged bleeding
• Lower abdominal/pelvic (± symptoms of
pregnancy)
• Weight gain or loss ( change in appetite )
• Headache
• Nausea/dizziness/vomiting
POPs-Side effects which may require
management

50. • Evaluate for pregnancy, especially if
amenorrhoea occurs after period of regular
menstrual cycles
• If not pregnant, counsel and reassure client
• Do not attempt to induce bleeding with COCs.
POPs- Management of Amenorrhea

51. • Reassurance
• Check for gynaecologic problem
• Short term treatment
– COC for 1 cycle
– ibuprofen
POPs : management of prolonged bleeding or
spotting

52. • 28-42 pills/pack
• Take one pill daily
• No break in between packs
• Within 3 hours of lowest at 20-24 hour after
ingestion; best taken at a time related to the
usual time of intercourse and not 20 hours
later
POPs

53. • Depo-provera (DMPA) –
150 mg of depot
medroxyprogesterone
acetate every 3/12
• Noristerat (NET-EN) :
200 mg of
norethindrone
enanthate give every
2/12
Injectable

54. • Highly effective (0.3
pregnancies per 100
women during first year
of use)
• Rapidly effective (<24
hours) if started on D7 of
menses
• Intermediate term
method (2-3 monthd
protection per injection )
• Do no interfere with
intercourse
• Do not affect breast
feeding
• Few side effects
• No supplies needed by
the client
• Can be provided by
trained non medical staff
• Contain no oestrogen
Injectable-contraceptive benefits

55. • Changes in menstrual
pattern
• Weight gain (~2 kg) is
common
• If pregnancy occurs, it is
more likely to be
ectopic than nonuser
• Resupply must be
available
• Must return for
injections every 3
months(DMPA) or 2
months(NET-EN)
• Return to fertility may
be delayed for 7-9
months (on average)
after discontinuation
Injectable-limitations

56. • Women of any reproductive age who;
– Have moderate to severe menstrual cramping
– Take drugs for epilepsy or tuberculosis
– Have high blood pressure or blood clotting
disorder
– Prefer not or should not use estrogen
– Cannot remember to take a pill every day
– Prefer a method not related to intercourse
Injectable-Indications

57. • Initial injection :
– Days 1 to 7 of the menstrual cycle
– Anytime during the menstrual cycle when you can be
reasonably sure the client is not pregnant
– Post partum :
• Immediately if not breast feeding
• After six months if using LAM
• Reinjection
– DMPA : up to 4 weeks early or late
– NET-EN : up to 2 weeks early or late
Injectable-timing of injection

58. DMPA NET-EN
Duration 3 months 2 months
Bleeding More amenorrhoea More irregular
Needle / pain Smaller / less Larger / more
Reinjection window Up to 4 weeks Up to 2 weeks
Cost Cheaper More expensive
Return to ovulation later sooner
Injectable-Comparison of DMPA and NET-EN

59. • The most common side effect
- irregular bleeding in 70 percent of women in
the first year.
- in 10 percent of women thereafter.
- Absence of bleeding is common in 80 percent
of women after two years.
Injectable-Side effects

60. Less common side effects:
Increased appetite and weight gain
Headaches
Sore breasts
Nausea
Depression
Nervousness
Dizziness
Skin rashes or spotty darkening of the skin
Hair loss or increased hair on face or body
Increased or decreased sexual desire
Injectable-Side effects

61. • Vaginal dryness
• Bone loss (reduce bone density)
• If pregnancy is desired, it takes 12 to 18 weeks
to get pregnant after the last shot is taken
(sometimes longer)
• In the rare case that pregnancy occurs during
the use of Depo Provera, there is an
increased chance that the pregnancy will be
ectopic.
Injectable-Side effects

62. Types
• Non medicated
– Lippes loop
• Medicated
– Copper-releasing
– Progestin-releasing
Intrauterine contraceptive device (IUCD)

63. • Copper releasing
• 1st
generation
– Copper seven
– Copper T 200
• 2nd
generation
– Multiload 250
– Nova T
• 3rd
generation
– Copper T380A
– Multiload 375
• Progestin releasing
• Progestasert
• LevoNova (LNG 20)
• Mirena
Chance of getting pregnant
Copper:
Typical use: 0.8 percent
Perfect use: 0.6 percent
Progesterone:
Typical use: 0.2 percent
Medicated IUCDs

64. • Effective immediately
• Long term method (up to 10
years protection with
copper T380A)
• Do not interfere with
intercourse
• Immediate return to fertility
upon removal
• Do not affect breast feeding
Mirena
• Decrease menstrual cramps
(progestin releasing only)
• Decrease menstrual
bleeding (progestin
releasing only)
IUCD-Benefits

65. • Increase menstrual
bleeding and cramping
during the first few
months (copper releasing
only)
• May be spontaneous
expelled
• Rarely (<1:1000)
perforation of uterus
during insertion
• Do not prevent all ectopic
pregnancies
• May increase risk of PID
and subsequent infertility
• Pelvic examination
required and screening
for STDs recommended
before insertion
• Required trained provider
for insertion and removal
• Need to check for strings
after menstrual period if
cramping, spotting or
pain
• Woman cannot stop use
whenever she wants
IUCD-Limitations

66. • Natural cycle, day 1-5 is
usual; if day 5 or any day
later(assuming no sexual
exposure up to that day)-
recommended additional
contraception for 7 days
• Following delivery or 2nd
trimester miscarriage(not
breastfeeding)-insertion
on about day 21 is
recommended
IUCD-Timing

67. • Copper releasing
– Heavier menstrual bleeding
– Irregular / heavy vaginal
bleeding
– Increased menstrual
cramping or pain
– Vaginal discharge
• Progestin releasing
– Amenorrhoea or very light
menstrual bleeding or
spotting
IUCD-Side effects

68. • May occur anytime after
insertion
• Most expulsions occur in
the first year and
particularly in the first 3
months
• Correct fundal placement is
thought to reduce expulsion
• Expulsion rates are higher
with an inexperienced
operator,
• insertion under 6 weeks
postpartum, nulliparous
and in women with heavy
painful menses
• Higher expulsion rates in
nulliparous women have
not been observed in recent
studies
• Women who expel an IUCD
have a 3-fold increased risk
of expelling the same or
another device
IUCD-Expulsion

69. The increased dose of
estrogen
(> 60% than the pills)
from the patch is
associated with blood
clots .
EVRA patch

70. `
• women with a history of blood
vessel disease such as diabetes,
heart disease or high blood
pressure
should not take this
medication.
EVRA patch

71. • Etonogestrel/EE
(0.120 mg /0.015 mg per
day)
Nuva Ring

72. Various types Contraceptive Efficacy (100 women in 1 year
use)
Abstinence 100% effective
Implants 0.05
Vasectomy 0.1
Levonorgestrel IUD 0.2
Tubal ligation 0.5
Injectable 0.3
Oral Hormone 0.3
Copper IUCD 0.6
LAM (6 months) 0.9
Male condom 2 (correct and consistent use)
Withdrawal 4
Diaphragms with spermicide 6
Contraception
Most
effective
Least
effective

73. • Within 72 H since last unprotective SI
1)Levonorgestrel (Prostinor)
0.75 mg bd or 1.5 mg od 1 day only
2)>72 H up to 5 days
IUCD (copper)
Emergency contraception

74. • Woman can choose method of contraception
that suite her needs
• All contraceptives method available should be
explained at timing of consultation
• More receptive for any side effect
experienced by the woman
• Woman with other associated problem,
consultation to the expert should be made.
Summary

75. Thank you