detailed information regarding Contraception

1. DR.R.MOHAN
Consultant Obstetrician &
Gynecologist
District Hospital,Saharsa
9/15/2017 1

2.  Contraception (birth control) prevents
pregnancy by interfering with the normal proce
ss ofovulation, fertilization, and implantation.
There are different kinds of birth control that
act at different points in the process.
9/15/2017 2

3. Barrier Methods
Diaphragm ;Cervical cap;Female condom
 Non Hormonal Methods - Centchroman (Saheli)
Hormonal Methods
 Oral contraceptive - Combined oestrogen/
progestogen; Progestogen only; EC -pill
 Depot progestogens – Combined , Progesterone
only
 Vaginal - rings releasing oestrogen & progestogen
 IUCD
9/15/2017 3

4.  Barrier Methods of contraception are meant
to stop the egg and sperm from coming in
contact and fertilizing.
 Some of the main types of barrier
contraceptives are male and female condoms,
cervical caps, diaphragms, sponges, and
dental dams
9/15/2017 4

5.  A male condom is one of the most common types
of barrier contraceptives
 It is made out of either latex, polyurethane, or
lamb skin
 It is put on over an erect penis before having sex
 They prevent the semen from entering the uterus
 Male condoms also prevent many STI’s (sexually
transmitted infections)
9/15/2017 5

6.  This type of contraceptive is put into the
vagina before having sex
 It has two ends with rings on them
 The end that goes into the vagina has a
closed rim
 The end that stays outside has an open rim
9/15/2017 6

7.  These are little rubber caps that are inserted
into the vagina and fits fits around the uterus
 This blocks the passage way for sperm to
enter the uterus
 This is used with spermicide
9/15/2017 7

8.  This is an actual sea sponge
 It is inserted into the vagina before sex
 It has spermicide on it which is a substance
that kills sperm
 This substance kills the sperm before it
enters the uterus
9/15/2017 8

9.  This is a dome shaped object that is also
made of rubber.
 Just like the cervical cap, it fits around the
cervix, preventing the sperm from being able
to enter the uterus
 This is used with spermicide
9/15/2017 9

10.  This contraceptive is mostly used during analingus
and cunnilingus .
 Dental dams are latex or polyurethane sheets used
between the mouth and vagina or anus during oral
sex.
 A dental dam prevents STI transmission .
 Before using a dental dam, a lubricant is usually
put on it .
9/15/2017 10

11. Female condom Dental dem
Diaphragm
Sponges
9/15/2017 11

12. Cervical Cap
Diaphragm
Spermicides
9/15/2017 12

13. 9/15/2017 13

14.  Centchroman (or 'Ormeloxifene') is a potent
non-steroidal non-hormonal birth control
method. Although it does not contain
hormones, it acts on the hormones produced
in the body, especially progesterone. It is a
once-a-week oral contraceptive which has
been proved to be not only highly effective
but also safe.
9/15/2017 14

15.  Centchroman acts at three points in the
reproductive cycle:
 It increases the movement of the fertilized
ovum through the fallopian tubes so that it
reaches the uterus too early when
the endometrium is not ready for implantation at
that time.
 It increases the rate of maturation of the ovum so
that it is hypermature when it reaches the
endometrium and fails to implant in it.
 It slows down the growth and development of the
endometrium so that it is not adequately
prepared to receive the fertilized ovum when it
reaches the uterus.
9/15/2017 15

16.  You’ve got to take Saheli twice a week for the
first three months. But after that you take just
one pill a week.
 Disadvantages :- Centchroman causes delayed
periods in some.
 There may be heavier periods in the first three
months with tender breasts, water retention
and some amount of acne.
 Periods can get scanty over time in some
women.
9/15/2017 16

17.  Combined oestrogen/ progestogen
 Progestogen only Pill
 Emergency Contraceptive Pill - ECP
9/15/2017 17

18.  you haven't used protection
 your normal contraception fails e.g. condom
splits
 you have missed more than one
contraceptive pill
 you have been vomiting or had diarrhoea
while on the pill
 you have missed your injection
 you have been forced to have sex without
contraception.
 You should not use the ECP as your regular
method of contraception
9/15/2017 18

19.  The ECP is taken after unprotected sex to
prevent pregnancy.
 It stops or delays the release of an egg from
your ovaries until sperm aren’t active in your
body any more.
 It doesn’t work once the egg has been
fertilised.
 It doesn’t harm you or a developing embryo.
 The ECP is approved to be taken up to 72 hours
after sex (three days). However for most
women it is still effective up to four days after
sex.
9/15/2017 19

20. It was first introduced in 1960
It has been used by millions of women
worldwide
9/15/2017 20

21. Two types of estrogens are used:
1 Ethinyl estradiole
2 Mestranol. Mestranol is converted in the
body to ethinyl estradiole.
Types of progestins used are :
 Estrane  Norethindrone, ethynodiol diacetate
 Gonane  Levonorgestrel, desogestrel,
norgestimate ( gonans more potent)
9/15/2017 21

22. Efficacy
 C OCP is highly effective 99.9% in preventing
pregnancy. However the user failure rate is 3-8%
 30% of women miss 3 or more pills in the 1st
cycle of use
 47% miss 1 or more pills
Indication
 Any women seeking a reversible, reliable, coitally-
independent method of contraception, in the absence
of contraindications .
9/15/2017 22

23. Mechanism of action
 Suppression of gonadotropin secretion  inhibition of ovulation (main
mechanism)
 Development of endometrial atrophy making it unreceptive to implantation
 Production of viscous Cx mucous that impede sperm transport
 Possible effect on the secretions & peristalsis of the fallopian tube interfering
with ovum & sperm transport
 Possible effect on the secretions & peristalsis of the fallopian tube interfering
with ovum & sperm transport
 Possible effect on the secretions & peristalsis of the fallopian tube interfering
with ovum & sperm transport
9/15/2017 23

24. Absolute contraindications
 < 6 Wk postpartum if breastfeeding
 Smoker ≥ 15 cigarettes/day, > 35 Y of age
 HPT systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg
 Current or past H/O of venous thromboembolism
 Ischemic heart disease
 H/O cerebrovascular accident
 Complicated valvular heart disease.
 Migraine headache with focal neurological
symptoms
 Current breast cancer
 Diabetes with retinopathy/ nephropathy/ neuropathy
 Severe liver cirrhosis
 Liver tumour ( adenoma or hepatoma)
9/15/2017 24

25. Non-contraceptive benefits
 Cycle regulation
 ↓↓ menstrual flow  ↓↓
anemia
 ↑↑ bone mineral density
 ↓↓ dysmenorrhea
 ↓↓ peri-menopausal
symptoms
 ↓↓ acne
 ↓↓ hirsutism
 ↓↓ ovarian ca 50% ↓↓ after
5 Y of use
 ↓↓ endometrial ca 50% ↓↓
 ↓↓ risk of fibroids
 Possibly ↓ ovarian cysts
 Possibly ↓ benign breast
disease
 Possibly ↓ colorectal ca
 ↓↓ incidence of salpingitis
 ↓↓ incidence or severity of
premenstrual syndrome
9/15/2017 25

26. Minor side-effects commonly occure during the 1st
3 cycles & may lead to unnecessary
discontinuation
1. Irregular bleeding (breakthrough bleeding/
spotting)
 10-30% in the 1st month of use
 improves with time over 3 cycles
 amenorrhea 2-3% of the cycles
2. Breast tenderness & nausea
 Improve with time
 Less with lower estrogen dosage
9/15/2017 26

27. 1-Venous thromboembolism
 VTE 3-4 X higher in users than nonusers
 The risk is attributed to the estrogen component of the pill & decline with lower
dosage
2- Myocardial infarction
 In the past with pills containing >50μg ethinyl estradiole --- 3X ↑↑ in MI
3-Stroke
 Smoking & HPT ↑↑ risk of stroke
4-Gallbladder disease
 COCP ↑↑ secretion of cholic acid in bile ↑↑ incidence of gallstone formation
5-Breast cancer
 Still controversial
6-Cervical cancer
 One study ↑↑ risk of Cx ca in long term COCP users who are HPV positive

28. 1-Breakthrough bleeding
 To continue on the same pills with the expectation
that it will improve with time .
 If bleeding persists beyond 3 months (or new onset
of bleeding in a long term user ) rule out other
causes of bleeding:
-irregular taking of the pills;
pregnancy;infections; uterine or Cx pathology;
malabsorption/ diarrhea , vomitting
Management of breakthrough bleeding
 Oral estrogens: premarine 1.25 mg or estradiole -
17 ß /7 days
 Change the another preparation with different
progestin

29. 2-Missed pills
 Take the pill as soon as you remember ( this means taking 2 in 1
day)
 If 2 pills in a row missed in the 1st 2 wks of the pack  take 2
/day for 2 days
 If 2 pills in a row missed in the 3rd wk of the pack  throw the
remainder of the pack & start a new one / use back up
contraception in the first 7 days of the new pack
 If 3 pills in a row missed  follow steps above
 If intercourse occurred after missing a pill  use emergency
contraception
3-Amenorrhea
 It occurs in 2-3% of COCP users--Pregnancy should be ruled out
4-Chloasma
 Darkening of the facial skin -Use of sunscreen to prevent further
darkening

30. 5-Breast tenderness & galactorrhea
 Often resolves with continued use
 ↓ caffeine intake may help
 ↓ estrogen content
6-Nausea
 ↓ with time
 Taking the pill with food or bedtime
 Rule out Pregnancy
7-Pregnancy
 Pills must be stopped immediately

31.  Delivers 150μg norgestimate & 20 μg E estradiole
daily
 One patch is applied weekly for 3 wks followed by
one patch-free-wk
Mechanism of action similar to COCP

32.  A flexible transparent ring 54 mm diameter /4 mm
cross-sectional diameter
 Releases 15μg E estradiole & o.12 mg of
desogestrel (etonogestrel)/ day
 Ring is used for 3 wks continuous followed by one
ring-free wk
 Vaginitis 13.7% (5% Rx related), coital problem or
expulsion 1-2.5%

34.  Package contains 28 tab
 Started on the 1st day of the menstrual cycle/ or any
day if pregnancy excluded
 Must be used at the same time every day within 3 hrs
 A back up contraception must be used for 7 days
 Norethindrone 0.35 mg  MICRONOR
 Must be used continuously  no pill-free interval
It can be used immediately postpartum with no effect
on lactation

35. 9/15/2017 35

36. Non contraceptive benefits
 ↓ menstrual flow
 10% amenorrhea
 ↓ dysmenorrhea, PMS
Side-effects
 Irregular bleeeding
 spotting –12%  1st month
--3%  18 months
40 % continue to have regular cycles
 Hormonal side-effects
Headache, bloating, acne, breast tenderness

37. 1-Irregular bleeding
 A common side effect
 Pregnancy, infection & genital pathology must be
ruled out
Rx options
 Non steroidal anti-inflammatory for 10 days
 Switching to COCP
 Adding a short course of estrogen
 0.625 mg conjugated equine estrogen
(premarine) for 28 days
1-2 mg micronized 17ß-estradiole—28 days
Transdermal 50-100 μg 17ß-estradiole patch –
25 days
 Antiprogestinic agents  mifepristone

38. 2-Missed pill
 To be taken as soon as possible
 Next pill to be taken at the regular time
 If delayed > 3hrs  use back up contraception
for 48 hrs
 If 2 or more pills missed in a row  2 pills/day
for 2 days back up contraception for 48 hrs
 Emergency contraception must be used if
intercourse occurred after a missed pill
3- Drug interactions  anticonvulsants may ↓↓
effectiveness of POP

39.  Desogestrel 75 mcg may be used while you
are breast-feeding. Desogestrel does not
influence the production or the quality of
breast milk
 The Desogestrel pack contains 28 tablets

40. Progesterone only
* DMPA – Depot medroxy progesterone
acetate
* NET-EN – Norethisterone Enanthate
* DMPA - Subcutaneous
Combined Injectables
9/15/2017 40

41. 9/15/2017 41

42.  How does DMPA works –
Preventing ovulation (egg release from the
ovary)
Thickening of the mucus of the cervix so that
sperm cannot enter the uterus (womb)
Advantages –
 long acting, effective method of contraception
 inexpensive
 undetectable by other people
 suitable for women who can’t take contraceptives
that contain oestrogen
9/15/2017 42

43. Who can use –
Most women are suitable, though it is best
between 18 and 50 years of age. It can be used
while breast feeding – a small amount of
hormone gets into the milk but does not alter the
quality of the milk.
DMPA contains a progestogen. This is similar to
the hormone progesterone, which is naturally
produced by the female body. DMPA is given by
injection every 12 weeks and is slowly absorbed
into the blood stream to prevent pregnancy.
Depo- Provera
Effectiveness - 99% if you are not late with the
injection
9/15/2017 43

44.  Noristerat - 1ml Noristerat contains 200mg
norethisterone enantate in oily solution .
 Intramuscularly provides contraception for
eight weeks ( 2 months ). The first injection
should be given within the first five days of a
menstrual cycle (the first day of menstruation
counting as day 1 )
9/15/2017 44

45. 9/15/2017 45

46.  Monthly injectable contraceptive composed of
5 mg estradiole cypionate & 25 mg
medroxyprogestrone acetate
 Less breakthrough bleeding
 Amenorrhea 14.6% compared to 3.3 in COCP
users
 Wt gain 4 pounds/year

47.  Monthly injectable contraceptive composed of
5 mg estradiole cypionate & 25 mg
medroxyprogestrone acetate - CYCLOFEM
 Or
 MESIGYNA – NET-EN 50mg + Oestradiol
valerate 5mg

48.  NORPLANT  Levonorgestril
 Implanon  Etonogestrel
 Highly effective failure rate 0.1% / year
 6 rods implanted under the skin  effective for 5
years
 Women < 70 kg effective for 7 Y pearl index < 2
 Reversible contraception
 Mechanism of action
 Suppression of ovulation
 Endometrial atrophy
 Rendering Cx mucous impermeable to sperms
 Prolonged irregular bleeding the major side effect

49. Causes spotting
Requires certified
clinician visits for
insertion and
removal

50. 9/15/2017 50

51. 9/15/2017 51

52.  Inara Cu 250 is one of the most effective
types of intrauterine devices used. Reversible
contraceptive in nature, the device offers a
protection term of up to 3 years.
9/15/2017 52

53. 9/15/2017 53

54.  Pregna Copper T 380A is a safe and
trusted birth control device to ease unwanted
pregnancy worries of the user for a period of
up to 10 years.
 The Pregna Copper T 380 A is amongst the
most effective methods available with less
then one percent failure rate.
 It is ideal for women who want to space their
children or are looking for long
term contraception.
9/15/2017 54

55.  A standout amongst the most generally
utilized copper bearing IUD is the Inara Cu
375. The Cu 375 is ideal for ladies who need
to space their youngsters for effective family
planning, as it is compelling for a time of 5
years.
9/15/2017 55

56.  Prevention of fertilization the chief
mechanism
 Inhibition of implantation
 Presence of foreign body & copper
biochemical & morphological changes in
the endometrium adversely affect sperm
transport
 Copper ion have direct effect on sperm
mobility  ↓↓ in its ability to penetrate Cx
mucous
9/15/2017 56

57.  Levonorgestrel releasing devices  weak foreign
body reaction & endometrial decidualization &
glandular atrophy estrogen & progestrone
receptors are ↓↓ Cx mucous becomes thick &
impermeable to sperms ovulation may be
inhibited in some women.
 Mirena contains 52 mg of levonorgestrel (LNG).
Initially, LNG is released at a rate of
approximately 20 mcg/day. This rate decreases
progressively to half that value after 5 years.
9/15/2017 57

58. 9/15/2017 58

59.  In the absence of contraindications may be
considered for any woman seeking a reliable,
reversible, coitally independent method of
contraception
 Women seeking long term birth control
 A method requiring less compliance
 Women with contraindications to estrogen
 Breast feeding women
 Copper IUCD used for postcoital contraception
within 7 days
 LNG- IUCD ↓↓ menstrual flow & cramping
suitable for women with menorrhagia &
dysmenorrhea

60. Absolute contraindications
 Pregnancy
 Current, recurrent or recent (within 3 M) PID or
sexually transmitted disease
 Puerperal sepsis
 Immediate post septic abortion
 Severely distorted uterine cavity
 Unexplained vaginal bleeding
 Cx or endometrial ca
 Malignant trophoblastic disease
 Copper allergy Copper -IUCD
 Breast ca  LNG -IUCD

61. Relative contraindications
 Risk factor for sexually transmitted diseases
or HIV
 Impaired response to infections:
-HIV +ve women
-Women on corticosteroid Rx
 48hrs- 4 wks postpartum
 Ovarian ca
 Benign gestational trophoblastic disease

62.  Nonmedicated IUCD or copper IUCD ↓ risk of
endometrial ca
 LNG-IUCD  ↓ menstrual blood loss 74-97% 
improved Hb
 LNG-IUCD users  ↓ hysterectomy for menorrhagia
64-80%
 LNG-IUCD  ↓ dysmenorrhea
 ---------------  protects against enometrial
hyperplasia in women on tamoxifen
 --------------  beneficial effects in fibroid related
menorrhagia

63. 1-Bleeding
Copper / nonmedicated IUCD
 Irregular menstrual bleeding
 ↑↑ amount of menstrual bleeding 65% in copper IUCD
users
 NSAID or tranexamic acid ↓↓menstrualblood loss
 The days of bleeding or spotting ↓↓ overtime 13 days inth
1st months  6 days at 1 year
 Discontinuation due to bleeding 20%
LNG-IUCD
 ↓↓menstrual blood loss 74-97%
 Spotting 16 days at 1 M ↓↓ 4 days at 12 M
 Discontinuation due to bleeding 14%
 Amenorrhea 16-35% at 12 M

64. 2-Pain or dysmenorrhea
 6% discontinue use due to pain
 Pain may be physiological
 LNG-IUCD ↓↓ dysmenorrhea
3-Hormonal LNG-IUCD
 Depression
 Acne
 Headache
 Breast tenderness
 Low incidence ,maximal at 3 M then ↓↓
 No change in Wt
4-Functional ovarian cysts/ LNG-IUCD
 30% of users
 Resolve spontaneously

65. 9/15/2017 65