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
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
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
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
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)
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
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.