SALSO Series - Contraception

1. DR EDAWATI
O&G DEPARTMENT
SGH

2.  HORMONAL
 ORAL
 INJECTABLE
 IMPLANT
 INTRAUTERINE CONTRACEPTIVE DEVICES
 BARRIER METHOD

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

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

5.  Holistic approach should be taken when
assisting woman in making contraceptives
choices
 Services should be organized to optimized
access and choices
 The method of birth control differ from each
other in the timing of when they are used

6.  Used specifically at the time of sexual
intercourse e.g. condoms,diaphragm
 Other method must be working all the time to
provide protection e.g. hormonal ,IUD and
sterilization.

7.  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
preperations

8.  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

9.  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

10.  Either fixed dose or phasic
 Phasic-the dose of oestrogen and progesterone
changes once(biphasic) or twice(triphasic) in
each 21 day course
 Phasic preparations are designed to mimic the
cyclical variations in hormone levels

11.  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

12.  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

13.  The endometrium becomes atrophic and
unreceptive to implantation
 Possibly direct effects on the fallopian tubes
impairing sperm migration and ovum
transport

14.  Effectiveness
 Depends on user
 < 1 pregnancy per 100 woman usedover 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

15.  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

16.  Fewer functional ovarian cysts
 Fewer extrauterine pregnancies
 Reduction in pelvic inflammatory ds
 Fewer symptomatic fibroids

17.  Probable reduction in thyroid diseases
 Probable reduction in risk of rheumatoid
arthritis

18.  Reduced risk of cancers of ovary and
endometrium
 Obvious beneficial social effects

19.  Weight gain:ass with 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/P rogestrogen and type of
progesterone used

20.  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

21.  COC containing 3rd generation
progestogens(desogestrel and gestodene)
possibly carry a small additional risk of VTE
compared to that of 2nd generation
 Risk of VTE is increased
by:obesity,immobility,age,congenital and
acquired thrombophilias

22.  Arterial disease:the 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.

23.  This risks increases with increasing oestrogen
doses and is greatly elevated by hypertension
and smoking

24.  Breast cancer-there is a small increase in the
risk of dev breast cancer while woman are
taking COC and for a few years after
discontinuing;diminishing to the background
risk after 10 years

25.  Ovarian&Endometrial cancer-there is >50%
reduction in the risk of dev ovarian and
endometrial cancer after 5 years of COC
usage,which lasts up to 15 years after the pill is
stopped

26.  Cancer of the cervix-an observed increase in
the incidence of both CIN and cervical cancer
in COC users maybe related to greater sexual
activity without the benefit of barrier
contraception in these women

27.  Trophoblast disease-recommended that all sex
hormones should be avoided while HCG levels
are raised.However no data to suggest an
increase risk of trophoblastic ds in pregnancies
following COC use

28.  Inherited and acquired thrombophilias
 Past cerebral haemorrhage
 Vascular malformation of the brain
 Significant structural heart ds
 Pulmonary hypertension

29.  Proven past arterial or venous thrombosis
 IHD
 Severe multiple risk factors for venous or
arterial ds
 Focal migraine
 TIA
 Artherogenic lipid disorders

30.  Active liver ds(i.e.with abnormal liver function
test)
 Liver adenoma or carcinoma
 Gallstones
 Acute hepatic porphyrias

31.  Pregnancy
 Undiagnosed genital tract bleeding
 Oestrogen dependent neoplasms,e.g breast
cancer

32.  Undiagnosed oligomenorrhoea
 Cigarette smoking above age 35
 Diabetes
 Non focal migraine
 Sickle cell disease
 Inflammatory bowel ds
 Obesity(if ass with other risk factors)

33.  Controlled by the woman
 Stopped at any time without health provider
help
 Do not interfere with sexual activity

34.  Safe and suitable for nearly all woman
 At any age including adolescent woman > 40
 Following a miscarriage
 Without pelvic examination
 Without cervical cancer screening
 Without a breast examination

35.  Progestin-only pills
 Depo-provera
 Norplant
 Implanon

36. POP

37.  Suppress ovulation
 Reduce sperm transport in upper genital tract
(fallopian tubes)
 Thicken cervical mucus
 preventing sperm penetration

38.  Effective when taken at the same time daily (
0.05-5 pregnancies per 100 )
 Immediately effective (<24 hours)
 Do not interfere with intercourse
 Do not affect breast feeding
 Immediate return to fertility when stopped

39.  Few side effects
 Convenient and easy to use
 Client can stop use
 Can be provided by trained nonmedical staff
 Contain no oestrogen

40.  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

41.  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

42.  POPs are not recommended unless other
methods are not available or acceptable if
woman ;
 Is breastfeeding (<6/52 post partum)
 Has unexplained vaginal bleeding (if suspected
serious problem)
 Has breast cancer (current / with h/o )
 Is jaundiced (active, sx)

43.  Is taking drugs for epilepsy
(phenytoin/barbiturates) or TB (rifampicin)
 Has severe cirrhosis
 Has liver tumours
 Has had a stroke
 Has IHD

44.  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)

45.  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
 Postabortion (immediately)

46.  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

47.  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.

48.  Reassurance
 Check for gynaecologic problem
 Short term treatment
 COC for 1 cycle
 ibuprofen

49.  ‘minipill’
 Contain one-half to one-tenth as much
progestin as COC
 Noriday
 Microva

50.  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

51.  Depo-provera (DMPA) – 150 mg of depot
medroxyprogesterone acetate every 3/12
 Noristerat (NET-EN) : 200 mg of norethindrone
enanthate given every two months

52.  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

53.  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

54.  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

55.  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

56.  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 ealy or late
 NET-EN : up to 2 weeks early or late

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

58.  Adequate training in counseling and provision
 Steady supply (DMPA, NET-EN, antiseptics
and needle and syringes)
 Recommended infection prevention practices
 Correct disposal or processing of syringes
 System for notifying clients when return for
injections
 Referral system
 supervision

59.  Six thin, flexible capsules filled with
levonorgestrel (LNG) that are inserted just
under the skin of a woman’s upper arm

60.  Highly effective (0.05-1 pregnancies per 100
women during the first year of use )
 Rapidly effective (<24 hours)
 Long term method ( up to 5 years)
 Pelvic examination not required prior to use
 Do not interfere with intercourse
 Do not affect breastfeeding
 [Trussell et al 1996]

61.  Immediate return to fertility on removal
 Few side effects
 Client needs to return to clinic only if problems
 No supplies needed by client
 Can be provided by trained nonphysician
(nurse or midwive)
 Contains no oestrogen

62.  Cause changes in menstrual pattern (irregular
bleeding/spotting initially ) in most women.
 Require trained provider for insertion and
removal
 Woman must return to healthcare provider or
clinic for insertion of another set of capsules or
removal

63.  Woman cannot stop whenever she wants
(provider dependent)
 Effectiveness may be lowered when certain
drugs for epilepsy (phenytoin and barbiturates)
or tuberculosis (rifampicin) are taken
 Cost effectiveness dependant on length of use
 Do not protect against STDs : (e.g HPV, HIV )

64.  Wash client’s entire arm and hand with soap
and water prior to antiseptic prep
 Use sterile or high-level disinfected
instruments, surgical glovesvand other items.
 After use, decontaminate all items
 Place disposable (needle and syringe) and
waste items in a puncture-proof container prior
to disposal
 Clean and final process reusable items by
sterilization (or high level disinfection)

65.  Anytime you can reasonable sure the client is
not pregnant
 Day 1-7 of the menstrual cycle
 Post partum
 After 6 months if using LAM
 After 6 weeks if breastfeeding but not using LAM
 Immediately or within 6 weeks if not breastfeeding
 Post abortion (immediately or within the first 7
days)

66.  Keep incision area dry for 48 hours
 Keep pressure bandage on for 48 hours and
leave Band-Aid on until incision heals (3-5
days)
 Bruising, swelling and tenderness at insertion
site are common
 Routine work can be done immediately. Avoid
bumping on the area, carrying heavy loads or
applying unusual pressure to incision site
 After healing, area can be touched and washed
with normal pressure

67.  Rate controlling
membrane (0.06
mm)
 Length : 40 mm
 Core diameter : 2
mm
 Core : 40% EVA
 60% etonogestrel
 Membrane : 100%
EVA

68. Implanon Norplant Norplant
1-3 years 1st year 5th year
Cycles 73,429 157,729 10,855
Pregnancies 0 24 9
Pearl index 0 0.2 1.1

69.  MOA-ovulation inhibition,supplemented by
mucus and endometrial effects
 Duration of use is 3 years,with the unique
distinction of a zero failure rate in pre
marketing trials(95% CI ranges upto 7 in
10,000)

70.  In international studies,serum levels tended to
be lower in heavier women,but there were no
failures,whatever the BMI
 Though much easier than Norplant to
insert/remove,specific training is required
 Mean insertion time-1.1 minutes
 Mean removal time-2.6 minutes

71.  Removal problems correlate with initially too-
deep insertion.
 Beware particularly of the thin or very
muscular woman with very little subcutaneous
tissue.Insertion can easily permit a segment of
the rod to enter the biceps muscle with deep
migration following.

72.  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

73.  If breastfeeding insert after 6
weeks(manufacturer urges caution-uncertainty
about the(probably nil) effects of the tiny
amount of etonorgestrel reaching the breast
milk must be discussed)
 1st trimester miscarriage- insertion is best,or up
to 7 days;day 7 or later an added method such
as condom is recommended for 7 days

74.  Acne
 Headache
 Abdominal pain
 Breast pain
 Dizziness
 Mood changes(depression,emotional lability)
 Libido decrease
 Hair loss

75.  Any serious adv effect of COCs
 Recent breast cancer,not clearly in remission
 Acute porphyria,with hx of usual attack
 Recent trophoblatic ds until HCG levels are
normal
 Known or suspected pregnancy
 Hypersensitivity to any component
 Undiagnosed genital tract bleeding

76.  Immediate contraceptive efficacy
 Pearl index of 0
 Rapid return to fertility after removal
 Progestogen-only bleeding pattern
 Less bleeding than Norplant
 Low incidence of side effects
 Benefits regarding dysmenorrhoea
 Low impact on metabolic parameters
 Easy and rapid insertion and removal

77.  IUCDs have been used throughout the world
for more than 3 decades
 Current usage as of Jan 2002-127 million
women world wide
 Majority of users are in China
 In UK used by less than 5% of all contraceptive
users

78.  Non medicated
 Lippes loop
 Medicated
 Copper-releasing
 Progestin-releasing

79.  Copper releasing  Progestin releasing
 1st generation  Progestasert
 Copper seven  LevoNova (LNG 20)
 Copper T 200  Mirena
 2nd generation
 Multiload 250
 Nova T
 3rd generation
 Copper T380A
 Multiload 375

80.  Interfere with ability of sperm to pass through
uterine cavity
 Thicken cervical mucus
 Change endometrial lining
 Interfere with reproductive process before ova
reach uterine cavity

81.  Highly effective (0.6-0.8 pregnancies per 100
women during the first year of use for copper
T380A
 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

82.  Few side effects
 After follow up visit, client needs to return to
clinic only if problems
 No supplies needed by client
 Can be provided by trained nonphysician
 Inexpensive (copper T380A)

83.  Decrease menstrual cramps (progestin
releasing only)
 Decrease menstrual bleeding (progestin
releasing only)
 Decrease ectopic pregnancy (except
Progestasert)

84.  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

85.  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

86.  Pregnant
 Unexplained PV bleeding
 Current, recent PID
 Acute purulent discharge
 Distorted uterine cavity
 Malignant trophoblastic disease
 Known pelvic TB
 Genital tract cancer
 Active genital tract infection

87.  IUCDs are not recommended unless other
methods are not available / acceptable ;
 Benign trophoblastic disease
 More than one sexual partner
 A partner who has more than one sexual partner

88.  Anytime during the menstrual cycle when you
can be reasonably sure the client is not
pregnant
 Day 1 – 7 of the menstrual cycle
 Postpartum (immediately following delivery,
during the first 48 hours postpartum or after 4-
6 weeks; after 6/12 if using LAM
 Postabortion (immediately / within first 7
days)- with no evidence of pelvic infection.

89.  Copper releasing  Progestin releasing
 Heavier menstrual  Amenorrhoea or very
bleeding light menstrual
 Irregular / heavy bleeding or spotting
vaginal bleeding
 Increased menstrual
cramping or pain
 Vaginal discharge

90.  Pelvic examination to exclude CI,uterine
sounding and to ensure careful placement in
the uterine cavity is crucial
 Generally-procedure is straightforward and
uncomplicated
 Evidence of continuing competence in IUCD
fitting by 5 yearly recertification is provided
within the Faculty of Family Planning of the
RCOG postgrad training programme

91.  Anxious women,nulliparous women and
women with previous cervical
surgery/stenosis may benefit from analgesia
and/or paracervical block anaesthesia
 Paracervical block is associated with fewer
vasovagal attacks,less pain at and after
insertion and a lower removal rate for pain and
bleeding in the first year

92.  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 periods

93.  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
 However almost half the women requesting
reinsertion following expulsion,retain their
second device

94.  1.2/1000 insertion
 If pregnancy occurs as a sequel to a misplaced
and perforated IUD,urgent retrieval is
advisable to avoid bladder and bowel
adhesions
 Contradictory evidence concerning risk with
early postpartum fitting

95.  Farley, T.M.M et al; PID rate very low ( 1.6
cases per 1000 women)
 Usually during the first 20 days after insertion

96.  Levonorgestrel-releasing intrauterine
system(LNG IUS)
 Releases about 20microgram per 24 hours of
LNG from its polydimethylsiloxane
reservoir,through a rate limiting membrane
 Licensed for 5 years

97.  Contraceptive effects are local,through changes
to the cervical mucus and utero-tubal fluid
which impair sperm migration
 Endometrial changes impeding implantation
 Cumulative failure rate to 7 years was very
low,1.1 per 100 women in the large Sivin
study,even less to 5 years in Andersson et
al(European multicentre trial)

98.  Amount of LNG in blood is enough to give
unwanted hormone type side side effect im
some women;otherwise irregular light bleeding
is the main problem
 Return of fertility is rapid and appears to be
complete

99.  Dramatic reduction in amount and,after the
first few months,duration of blood loss
 Dysmenorrhoea is improved and PMS in some
 Ideal contraception for women with
menorrhagia or who are prone to iron def
anemia

100.  Liver tumour or severe active hepatocellular ds
 Hypersensitivity to LNG
 Trophoblastic ds(while blood HCG levels are
very high,no problem after recovery)
 Current breast cancer(usable on WHO 3 after 5
years in remission)

101.  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.