The document discusses the phases of the menstrual cycle and various contraceptive options, including behavioral methods, barrier methods, hormonal contraceptives, intrauterine devices, and sterilization. It describes the follicular, ovulatory, and luteal phases of the menstrual cycle and explains when during the cycle a woman is most fertile. The document provides details on how each contraceptive option works and its effectiveness in preventing pregnancy.

1. The Menstrual Cycle and
Contraception
MiniMedical School
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2. CASE STUDY
A sexually active woman usually takes her birth control pills
when she wakes up every morning for work at 7:00 AM. On
the weekends, she sets her alarm clock for 7:00 AM, takes
her pill, and then goes back to sleep.
A.Is this weekend ritual necessary?
B.What would happen if she slept through her alarm
clock and she took her pill at 7:30 AM?
C.At 11:00 AM?
D.If she continually sleeps in, should she switch her birth
control methods?
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3. The Menstrual Cycle
The menstrual cycle is a series of physical
changes that a fertile woman’s body goes through
for the purpose of sexual reproduction.
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4. The Menstrual
Cycle has
Three Main
Phases
•Follicular/Proliferati
ve Phase (includes
menstruation)
•Ovulatory Phase
•Luteal/Secretory
Phase
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5. Conception can occur at
ANY time during the
menstrual cycle!
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6. The Phases
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7. The Follicular/Proliferative Phase
•Includes menstruation, which is Day 1 (of 28) of the ovarian
cycle/menstrual cycle.
•Estrogen levels gradually rise, causing:
• The cessation of menstruation (end of sloughing off of endometrium)
• The formation of a new endometrium
• The production of cervical mucus which indicates the near release of an
ovum (egg).
•During this time, the follicle (proto-egg) is also developing after
stimulation via Follicle Stimulating Hormone (FSH) and will soon be
ready to be released from the ovary (ovulatory phase) into the
fallopian tubes.
•This phase usually lasts for about 12 days.
•The last two days of this phase is a peak time of fertility for most
women as it proceeds the ovulatory phase, when an ovum (egg) is
released.
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8. Ovulatory Phase
•Begins around Day 12 when Luteinizing Hormone (LH)
surges and causes the ovary walls to weaken and allow for
the release of the ovum from the follicle.
•The follicle ruptures and the ovum releases and is ready to
be fertilized, usually in the ampulla of the fallopian tubes
(widest part).
•During any given Ovarian Cycle, an ovum can come from
either the left or right ovary. Occasionally, an egg can be
released from both ovaries in the same cycle and, if
conception occurs, can lead to fraternal twins.
•This phase usually lasts for two days (until Day 14).
•These two days are also considered a peak time of fertility
for most women
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9. Luteal/Secretory Phase
•The Luteal Phase is characterized by a rise in progesterone that
is produced by the corpus luteum, which is the remnants of the
follicle released during the cycle.
•As Progesterone levels rise, they cause:
• Successful implantation of a fertilized egg (if conception occurs)
• Increase in body temperature (an indicator of fertility
•If conception does not occur, the corpus luteum degenerates and
progesterone levels decrease, thus triggering menstruation on
Day 28.
•This phase usually lasts for 14 days after the release of the
ovum.
•The first two days of the cycle (up to 48 hours after the release of
the ovum), is also a peak time of fertility for most women.
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10. Fertile Days
•Conception can occur at ANY time during the menstrual
cycle (from Day 1 to Day 28).
•Sperm can survive in the female reproductive tract up to
five days (average is usually 2-3 days).
•The ovum is able to be fertilized 1-2 days after its release.
•Therefore, the most fertile days during the cycle are, on
average, five days before and two days after the ovum is
released from the ovary (Days 10-16 if you follow the
average 28 day cycle with a Day 14 ovulation).
•Sexual intercourse during these days of high fertility is
discouraged if conception is not desired and if using certain
contraceptive measures.
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11. Menstrual Cycle and Intro to
Contraceptives
http://www.youtube.com/watch?v=TExPlAh1tCA&feature=related
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12. Contraceptives
•Contraceptives are used to either inhibit the
fertilization of an ovum or prevent the implantation of
a fertilized egg in the endometrium.
•The following are the types of available
contraceptives:
• Behavioral Methods
• Barrier Methods
• Hormonal Contraceptives
• Intrauterine Devices
• Sterilization
• Emergency Contraceptives
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13. Behavioral Methods
•Require no hormones or
medication.
•Their moderate
effectiveness depends on
consistent adherence
•Only risks are
inconvenience and failure as
a contraceptive
•Theses methods include:
• Withdrawl
• Periodic Abstinence
(Rythmic Method)
• Lactational Amenorrhea
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14. Behavioral Method: Withdrawal
•73 to 96% effective.
•Man must recognize point of ejaculation and withdrawal.
•This requires a high level of trust and self control.
•NOTE: Pre-ejaculate can contain live sperm and reduce
the effectiveness of this method. It is recommended that the
man urinates before intercourse to reduce the amount of
live sperm in pre-ejaculate.
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15. Behavioral Method: Periodic
Abstinence (Rythmic Method)
•75 to 88% effective
•Women predict ovulation by (1) tracking body temperature,
(2) checking consistency of cervical mucus, (3) charting
menstrual cycles on a calendar.
•Couples abstain from intercourse or use barrier method
from 5 days before ovulation to 2 days after ovulation
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16. Behavioral Method: Lactational
Amenorrhea
•95 to 98% effective
•Women must be
breastfeeding exclusively,
nursing at least ever 4
hours during the day and
at least every 6 hours
during the night.
•Discontinue this method
if (1) a menstrual period
occurs, (2), it has been 6
months since the birth of
the infant, or (3) the infant
nurses less often.
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17. Barrier Methods
•Attempt to prevent the fertilization of an ovum by physically
preventing sperm from entering the uterus.
•Condoms and spermicide are available without prescription
•Latex and polyurethane condoms protect against HIV and other
STDs
•Successful use of the barrier method as contraception requires
consistency and discipline.
•All barrier methods are safe for use during lactation.
•Types of barrier methods:
• Male Condoms
• Female Condoms
• Cervical Caps (not in USA)
• Diaphragm
• Spermicide
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18. Barrier Method: Male Condoms
•85 to 98% effective for pregnancy prevention
•A new condom must be used each time a couple engages
in intercourse
•Can prevent transmission of HIV and STDs
•Can help with premature ejaculation
•Disadvantages include (1) Latex allergies, (2) loss of
sensation, (3) inconvenience/interruption of sexual
intercourse, (4) slippage and breakage
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19. Barrier Method: Female
Condoms
•75 to 95% effective
•It is a lubricated polyurethane pouch
that is inserted in the vagina during
sex.
•A new condom must be used each
time a couple engages in intercourse
•Can prevent transmission of HIV and
STDs
•Disadvantages include (1)
friction/noise during intercourse, (2)
loss of sensation, (3)
inconvenience/interruption of sexual
intercourse, (4) slippage and breakage
(higher incidence than male condom)
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20. Barrier Method:
Diaphragm
•84 to 94% effective
•Must be fitted initially and prescribed by
clinicians trained in their use.
•Must be filled and coated with spermicide
and inserted before intercourse.
•More spermicide should be inserted with an
applicator for each session of intercourse.
•Does not prevent HIV transmission
•Disadvantages include (1) possible skin
irritation, (2) possible increased risk of
bladder infection, (3) possible increased risk
of HIV transmission (spermacide may
actually increase the risk of HIV
transmission.
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21. Barrier Method: Spermicide
•71 to 85% effective
•Comes in several forms: gel, sponge, foam, inserts.
•Must be inserted each time a couple has intercourse.
•Disadvantages include (1) possible skin irritation, (2)
possible increased risk of HIV transmission (spermacide
may actually increase the risk of HIV transmission.
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22. Hormonal
Contraceptives
•Attempts to prevent fertilization of the ovum or ovulation itself via the use of progesterone
and estrogen (combined contraceptives) or just progesterone.
•Combined contraceptives (progesterone/estrogen)
• Act by preventing ovulation
• Can be dispensed via pill (daily), patch (weekly), or vaginal ring (monthly)
• Benefits include: improvement of menorrhagia, acne, reduced risk of ovarian
cancer, quick return to fertility with discontinued use.
• Side effects can include: nausea, spotting,
• Contraindications for use: Migraine with aura, smoking, stroke, ischemic heart
disease, liver disease, major surgery with immobilization, hypertension, breast
cancer, deep vein thrombosis.
• Types: Pill “The Pill”, Patch, Ring
•Progesterone-only contraceptives
• Act by thickening cervical mucus, thus becoming a barrier to sperm entering the
uterus.
• Can be dispensed via pill (daily), injection, intrauterine device, or implant.
• Well-suited to women who cannot take estrogen (breastfeeding, etc.)
• Common side effects include: spotting, hair or skin changes, weight gain,
headaches, depression, decreased libido.
• Types: Pill “The Mini Pill”, Injection,
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23. Combined Contraceptives: “The Pill”
•92 to 99% effective
•Can be a monophasic or multiphasic pill
•Usually 28 pills per pack with 21-24 active pills and 7-4
placebo pills for menstruation. The decrease in
progesterone causes the sloughing off of the endometrium
and the commencement of menses.
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24. Combined Contraceptives: Patch
•92 to 99% effective
•Get three patches for each month. Must apply a new patch
each week. Each patch releases enough hormones to last 9
days, so if a day or two late changing patch, not much risk
of unintended pregnancy.
•NOTE: the patch is less effective in women who are more
than 198 pounds.
•Additional side effects are skin irritation and an increased
risk of thromboembolic complications due to it’s higher level
of estrogen (compared to the pill and ring)
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25. Combined Contraceptives: Ring
•92 to 99% effective
•Women insert a new ring for three weeks and take out the ring in the 4th week.
•NOTE: since each ring contained enough hormones for 35 days, if women do
not take out their ring for 10 to 15 days after 3 weeks, there is little chance of
interrupted contraception.
•The ring can be used for extended cycling (no ring-free interval). However, it is
recommended, that menstruation should occur at least every 3 months.
•Women can remove the ring during intercourse for up to 3 hours per day
without loosing contraceptive efficacy.
•Some side effects included increased vaginal discharge and about 2% of
women find the ring is expelled spontaneously.
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26. Progesterone-only Contraceptives: Pill
•The “minipill”
•92 to 99% effective
•MUST take the pill at the SAME TIME
each day. Women who take the pill
more than 3 hours late should use a
back-up method (barrier method) for 1
week.
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27. Progesterone-only Contraceptives:
Injection
•97 to 99% effective
•Creates an intramuscular depot of medroxyprogesteron acetate (DMPA)
•Women receive an injection in a medical office or in a self-administered form
every 12 to 14 weeks.
•Progesterone injection lowers the risk of ovarian and endometrial cancer.
•After 2 or more cycles, many women become amenorrheic (no longer have
menses)
•Progesterone injections cause a temporary decrease in bone density. Bone
density stabilized after 2 years of use and returns to baseline levels after the
method is discontinued.
•Side effects and lowered fertility may be present for months after women
discontinue use.
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28. Progesterone-only Contraceptives:
Implant
•99% effective
•A single-rod contraceptive device inserted subdermally in
the upper arm. It releases entnogestrel for 3 years.
•It must be inserted and removed by a clinician trained in its
use.
•Fertility returns quickly when implant is removed.
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29. Benefits of Hormonal
Contraceptives
•Continuous use of hormonal contraceptives eliminate menses and benefit women with the below
conditions:
• Menorrhagia
• Dysmenorrhea
• Premenstrual syndrome (PMS)
• Endometriosis
• Menstrual migraines
• Irregular menses
• Iron-deficiency anemia,
• Menstrual flares of rheumatoid arthritis, coagulation defects, (menstrual porhyria).
•Combined Hormonal Contraceptives also alleviation the below nonmenstrual conditions:
• Acne
• Hirsutism
• Polycyctic ovarian syndrome
• Preimenopause
•Combined Hormonal Contraceptives also reduce the risk of:
• Ovarian cancer
• Endometrial cancer
• Osteoperosis
• Colorectal cancer *

30. Intrauterine Devices (IUD)
•These are devices placed in the uterus to prevent conception
by suppressing ovulation and thickening cervical mucus.
•They are highly effective, well tolerated, long-acting and
reversible.
•For women who do not plan on becoming pregnancy in the
next two years, IUD’s are the most cost-effective
contraceptive.
•Suited for women who cannot take estrogen, for those who
have never born a child, and for those with STDs
•There is a risk of uterine perforation, infection and expulsion
within the first year.
•Fertility returns quickly after removal.
•There are two types available:
• Copper IUD
• Progestin IUD
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31. Copper IUD
•99% effective
•Acts by disrupting sperm mobility and
damaging sperm so fertilization does not
take place.
•Remains effective for 10 to 12 years.
•Often causes heavier, more painful
periods the first few cycles. Less often, it
causes irritation of partner’s penis during
intercourse (this problem can be fixed by
cutting the IUD string shorter.
•It can be used as an emergency
contraceptive up to five days after
intercourse.
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32. Progestin IUD
•99% effective
•Acts by changing progesterone levels in
the uterine environment, thereby
disrupting the menstrual cycle and even
preventing menstruation all together
(most women become amenorrhetic after
6 to 12 months).
•Common side effects include: spotting,
irritation of partner’s penis during
intercourse, bloating, nausea,
headaches, breast pain
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33. Sterilization
•Sterilization provides permanent,
non-reversible protection against
pregnancy.
•There are several procedures for
men and women
•Male sterilization procedures cost
less and carry less risk than
female sterilization, however, in
the US, female sterilization is
preformed more often than male
sterilization.
•Female Procedure: Tubal
Sterilization
•Male Procedure: Vasectomy
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34. Tubal Sterilization
•99% effective
•Surgical procedure for sterilization in which a woman's
fallopian tubes are clamped and blocked, or severed and
sealed, either method of which prevents eggs from
reaching the uterus for fertilization.
•These techniques can be preformed laproscopically,
abdominally, hysteroscopically, or transvaginally.
•Risks include infection and bleeding during the procedure
•Post procedural regret is highest among young women,
and so young women should look to long lasting devices,
like IUD’s,
•Women who have undergone this procedure and wish to
conceive can undergo microsurgical repair of their fallopian
tubes or in vitro fertilization.
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35. Vasectomy
•99% effective
•Provided permanent, non-reversible protection against pregnancy
•Preformed using local anesthetics with incision or no-incision techniques.
•Risks include: infection, bleeding, scrotal pain or swelling at time of procedure
•It DOES NOT increase the risk of testicular or prostate cancer.
•Twelve weeks after the procedure, men should undergo a semen analysis to
insure complete sterilization. Until the semen analysis shows aspermia, other
forms of contraceptives should be used.
•Post procedural regret is highest among young men. In about 70% of the
cases, microsurgery can be used to reverse the procedure within 3 years of the
procedure with decreasing rates of reversal the longer its been since the initial
surgery.
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36. *

37. Emergency Contraceptives
•Lower the risk of pregnancy following unprotected
intercourse.
•There are four types:
• Progestin-only (levonorgestrel) Pill
• Estrogen/Progestin Pill
• Copper IUD
• Selective Progesterone Receptor Modulator (ulipristal)
Pill
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38. Progestin-only (Levonorgestrel) Pill
•Taken within 72 hours, this method reduces the risk of
pregnancy by 89%.
•This method does not disrupt an implanted pregnancy
•This method prevents or delays ovulation
•Available without prescription in the us to women over the
age of 17.
•Side effects include: Nausea, spotting, change in timing of
menstruation
•If vomiting occurs less than 2 hours after taking the
emergency contraception, you may need to repeat the
dose.
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39. Estrogen/Progestin Pill
•Taken within 72 hours, this method reduces the risk of
pregnancy by 75%.
•This method does not disrupt an implanted pregnancy
•This method prevents or delays ovulation
•Causes more nausea than the progestin-only emergency
contraceptive pill
•Side effects include: Nausea, vomiting, spotting, change in
time of menstruation.
•If vomiting occurs less than 2 hours after taking the
emergency contraception, you may need to repeat the
dose.
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40. Copper IUD
•Nearly 100% effective up to 5 days after intercourse
•Prevents fertilization and implantation.
•Most effective emergency contraceptive and best method
for women who desire an IUD for long-term contraception
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41. Selective Progesterone Receptor
Modulator (Ulipristal) Pill
•Taken within 5 days of unprotected sex, it reduces the risk
of pregnancy by 90%
•Mechanism of action is uncertain, however, it is believed to
work by delaying ovulation and through endometrial effects.
•Side effects includes: headache, dizziness, abdominal
pain.
•If vomiting occurs less than 3 hours after taking the
emergency contraception, you may need to repeat the
dose.
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42. Method vs. Actual
Effectiveness
•Method
effectiveness is how
effective the method
is, if used
appropriately and
correctly, in
preventing
pregnancy (i.e.
Lowest Expected
Rate).
•Actual
effectiveness (is
how effective the
method is for all
those who intended
to use it to prevent
pregnancy (i.e.
Typical Use Rate).
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43. CASE STUDY
A sexually active woman usually takes her birth control pills
when she wakes up every morning for work at 7:00 AM. On
the weekends, she sets her alarm clock for 7:00 AM, takes
her pill, and then goes back to sleep.
A.Is this weekend ritual necessary?
B.What would happen if she slept through her alarm
clock and she took her pill at 7:30 AM?
C.At 11:00 AM?
D.If she continually sleeps in, should she switch her birth
control methods?
*

44. CASE STUDY
A sexually active woman usually takes her birth control pills
when she wakes up every morning for work at 7:00 AM. On
the weekends, she sets her alarm clock for 7:00 AM, takes
her pill, and then goes back to sleep.
A.Is this weekend ritual necessary? YES
B.What would happen if she slept through her alarm
clock and she took her pill at 7:30 AM?
C.At 11:00 AM?
D.If she continually sleeps in, should she switch her birth
control methods?
*

45. CASE STUDY
A sexually active woman usually takes her birth control pills
when she wakes up every morning for work at 7:00 AM. On
the weekends, she sets her alarm clock for 7:00 AM, takes
her pill, and then goes back to sleep.
A.Is this weekend ritual necessary? YES
B.What would happen if she slept through her alarm
clock and she took her pill at 7:30 AM? NOTHING
C.At 11:00 AM?
D.If she continually sleeps in, should she switch her birth
control methods?
*

46. CASE STUDY
A sexually active woman usually takes her birth control pills
when she wakes up every morning for work at 7:00 AM. On
the weekends, she sets her alarm clock for 7:00 AM, takes
her pill, and then goes back to sleep.
A.Is this weekend ritual necessary? YES
B.What would happen if she slept through her alarm
clock and she took her pill at 7:30 AM? NOTHING
C.At 11:00 AM? She would need to use alternative birth
control methods (e.g. barrier) to insure proper birth
control.
D.If she continually sleeps in, should she switch her birth
control methods?
*

47. CASE STUDY
A sexually active woman usually takes her birth control pills
when she wakes up every morning for work at 7:00 AM. On
the weekends, she sets her alarm clock for 7:00 AM, takes
her pill, and then goes back to sleep.
A.Is this weekend ritual necessary? YES
B.What would happen if she slept through her alarm
clock and she took her pill at 7:30 AM? NOTHING
C.At 11:00 AM? She would need to use alternative birth
control methods (e.g. barrier) to insure proper birth
control.
D.If she continually sleeps in, should she switch her birth
control methods? YES
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48. Questions?
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