CONTRACEPTIO

N&
STERILIZATION

Family Planning
 FAMILY PLANNING
“for sexually active fertile
women not using contraception,
pregnancy rates approach 90 percent
at 1 year”
 CONTRACEPTION
• Implants and intrauterine devices are
found in the top tier
–effective in lowering unintended
pregnancy rates
–long-acting reversible contraception
(LARC)
 CONTRACEPTION
• 6 Groups:
1. combination hormonal contraceptives (CHCs)
2. progestin-only pills (POPs)
3. depot medroxyprogesterone acetate (DMPA)
4. implants
5. levonorgestrel-releasing intrauterine system
(LNG-IUS)
6. copper intrauterine devices (Cu-IUDs)
 I - LONG-ACTING REVERSIBLE
CONTRACEPTION: INTRAUTERINE
DEVICES

• INTRAUTERINE DEVICES (IUD)

–Most commonly used method of
reversible contraception worldwide
 LONG-ACTING REVERSIBLE CONTRACEPTION:
INTRAUTERINE DEVICES
• INTRAUTERINE DEVICES (IUD)
– US approved IUDs
• chemically active and have continuous
elution of copper or progestin
• 2 different levonorgestrel-releasing
intrauterine systems:
Mirena and Skyla
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES

• Mirena and Skyla

– Release progestin into the uterus at a relatively
constant rate
– T-shaped radiopaque frames have a stem
wrapped with a cylinder reservoir that contains
the levonorgestrel
– two trailing brown strings attached to the stem
– Failure rate: <1%
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• Types
– Mirena - 5 years
– Skyla - 3 years
• nulliparous
uterus
• silver ring near
the junction of
the device’s
stem and arms
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• Types
– ParaGard (T 380A) – 10
years
• polyethylene and
barium sulfate T-
shaped frame wound
with copper
• two strings extend
from the stem base
• White string
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• MOA: not been precisely defined
• intense local endometrial inflammatory response
esp. by the copper-containing devices
• Cellular and humoral components of this
inflammation are expressed in endometrial tissue
and in fluid filling the uterine cavity and fallopian
tubes
• Decreased sperm and egg viability
• Fertilization - same inflammatory actions are
directed against the blastocysts
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• The endometrium is transformed into a hostile site for implantation.
• Copper IUD
– copper levels increase in the cervical mucus of users and decrease
sperm motility and viability
• LNG-IUS
– inflammatory reaction
– endometrial atrophy, which hinders normal implantation
– scant viscous cervical mucus that obstructs sperm motility
– inconsistently release sufficient progestin to inhibit ovulation,
although this is a lesser effect than its local actions
LONG-ACTING REVERSIBLE CONTRACEPTION:
INTRAUTERINE DEVICES
 LONG-ACTING REVERSIBLE CONTRACEPTION:
INTRAUTERINE DEVICES

• Method-Specific Adverse Effects:

1. Uterine perforation – 1 in 1000 insertions
• At time of insertion
• Fundal perforation (m.c.)
2. Device expulsion
• First month
• If tail is not visualized:
• Device expelled
• Perforation
• Malpositioned
• Imaging: UTZ, radiograph, Ctscan, MRI
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• Method-Specific Adverse Effects:
3.Menstrual changes – dysmenorrhea - NSAIDs

menorrhagia- iron suppl

4. Infection – inc risk in the 1st 20 days

identify STDs & treat

Broad espectrum antibiotics

 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• Method-Specific Adverse Effects:
5.Miscarriage if pregnancy occurs

(+)- exclude ectopic pregnancy

w/IUP until 14wks  remove

risk for malformation not clear

2nd Tri miscarriage w/IUD – more likely infected

pregnant w/ pelvic infection: intensive antibiotic

 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• Method-Specific Adverse Effects:
6.Lower the absolute number of ectopic pregnancies –
50%
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
INTRAUTERINE DEVICES
• Timing:
– Immediately after miscarriage and surgical abortion
– 1 week after medical abortion
– Delivery (vaginal or CS)
• To reduce expulsion rate – at least after 6 weeks or
involution is complete
– End of normal menstruation
• Cervix is softer and more dilated
• Exclude early pregnancy
 IUD Insertion:

• Identify contraindications
• Secure consent
• Bimanual pelvic exam to ascertain uterine
position & size
• Abnormalities identified
Treat mucopurulent cervicitis/significant
cervicitis
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
PROGESTIN IMPLANTS

• Etonogestrel Implant
– thin, pliable progestin-containing cylinders that
are implanted subdermally and release hormone
over many years
• Implanon
– single-rod implant with 68 mg of etonogestrel covered by an
ethylene vinyl acetate copolymer
– subdermally on the medial surface of the upper arm 8 to 10
cm from the elbow in the biceps groove and is aligned with
the long axis of the arm
– 3 years
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
PROGESTIN IMPLANTS

• Etonogestrel Implant
– Nexplanon – radiopaque,
similar with implanon
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
PROGESTIN IMPLANTS
• Levonorgestrel Implants
– first progestin implants contained levonorgestrel
– Same procedure for insertion w/ Etonogestrel
• Jadelle (Norplant-2)
– 150mg Levonorgestrel
– 5 years
– new rods inserted at the same site
• Sino-Implant II
– 4 years
– two subdermally implanted Silastic rods
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
PROGESTIN IMPLANTS
• Method-Specific Adverse Effects:

– Malpositioning
• branches of the medial antebrachial cutaneous nerve
can be injured if placed too deep
– numbness and paresthesia over the anteromedial aspect of the
forearm
• nonpalpable devices
• Radiologic imaging for localiztion
• Blood level determination to verify implant in situ
 LONG-ACTING REVERSIBLE
CONTRACEPTION:
PROGESTIN IMPLANTS
• Insertion:
– Within 5 days of menses onset
– If inserted later in the cycle, then alternative
contraception is recommended for 7 days
following placement
– contraception is established within 24 hours
– For transitioning methods:
• COC – first placebo day
• DMPA – on the day of next injection is due
• POP – within 24 hours of last POP
 II - PROGESTIN – ONLY
CONTRACEPTIVE GROUP
• Implants, pills, injectables
• 1º Action: Suppress luteinizing hormone (LH)
and in
turn block ovulation
• Other actions:
cervical mucus is thickened to retard sperm
passage
atrophy renders the endometrium unfavorable for
implantation
PROGESTIN – ONLY CONTRACEPTIVE GROUP

1. irregular uterine bleeding

– metrorrhagia or menorrhagia
– most frequently reported adverse event
2. Amenorrhea – with prolonged use

• NOT significantly affect lipid metabolism,

glucose levels, hemostatic factors, liver
function, thyroid function, and blood pressure
• NOT been shown to increase the risk for
 PROGESTIN – ONLY
CONTRACEPTIVE GROUP

• DMPA – ↑ LDL cholesterol level

↓ HDL cholesterol level

• do not impair milk production

• no increased risks of genital tract or breast

neoplasia

• Weight gain and bone mineral density loss are

not prominent side effects except for DMPA
 Risk category score (table 38-3)
1 = no contraindications
2 = method benefits outweigh risks
3 = method risks outweigh benefits
4 = method poses an unacceptably high
health risk

Assoc risks that ↑ category score:

age >/= 35y.o,
transfusion at delivery
 PROGESTIN – ONLY
CONTRACEPTIVE GROUP

• CONTRAINDICATIONS
– Absolute:
• Current breast cancer
• Pregnancy

– Thrombosis and Thromboembolism

– Prior ectopic pregnancy
 III - VERY EFFECTIVE CONTRACEPTION:
• Pills, injectable
HORMONAL CONTRACEPTIVES rings,
progestins,transvaginal
transdermal patches

• Second tier agents due to the need for patient

compliance
 Combination Hormonal
Contraception

suppression of hypothalamic
gonadotropin-releasing factors

blocks pituitary secretion of follicle-

stimulating hormone (FSH) and LH to inhibit
ovulation

progestin component provides

Estrogen blocks ovulation by
ovulation prevention by
suppressing FSH release
suppressing LH

thicken cervical mucus and thereby retard

stabilizes the endometrium, which
sperm passage; and they render the
endometrium unfavorable for implantation
prevents intermenstrual bleeding
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
• Combined OCP)
• most frequently used method
• ethinyl estradiol – m.c. estrogen present
• mestranol or estradiol valerate (less frequent)
• Unwanted effects:
» breast tenderness
» fluid retention
» weight gain
» nausea
» headache
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
• Combined OCP
• Progestin
– Most are related to testosterone
– impart androgenic side effects :
- acne
- adverse LDL & HDL effects
- to avoid: progestins more structurally R/T to
progestone molecule have been developed:
– Medroxyprogesterone acetate – only in injectable forms
– Drospirenone
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
• Combined OCP
• Progestin
– Drospirenone –similar to spironolactone
- androgenic
- antialdosterone
- antimineralocorticoid: SeK retention
- avoided in renal/adrenal insuff or
hepatic dysfuncton
- SeK monitoring if used w/ drugs assoc w/
K retention: NSAIDS,ACE inhibitors, etc
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Combined OCP
– Low dose estrogen and progesterin content –
minimize adverse effects

– Lowest acceptable dose: 10 to 50 ug of ethinyl

estradiol

– Most contain: 35 ug or less

 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Combined OCP

– Phasic pills – developed to reduce the total progestin

content per cycle without sacrificing contraceptive effect

– Dose changes: Monophasic, biphasic, triphasic or

quadriphasic
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Combined OCP
• Phasic pills
• Monophasic = progestin dose remains constant throughout the cycle,
same amount of estrogen and progestin every day.

• Biphasic = same amount for the 1st 21 days

1st half: progestin/estrogen ratio is lower  Endometrium
thickens
2nd half: progestin/estrogen ratio is higher  shedding of EM

• Triphasic = birth control pills have constant or changing estrogen

concentrations and varying progestin concentrations throughout the cycle
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
• daily for a specified time (21 to 81
days)

• Replaced by placebo for a specified

time (4 to 7 days) - “pill-free interval”

• pill-free days - withdrawal bleeding is

expected

• 1st day of menses

• “Quick start method” = addl
• method is used x 7days
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Method Specific Effects

– Altered drug efficacy = COC interfer w/the
actions of some drugs (table 38-5)

– Drugs↓ COC effectiveness:

• Anti-tubercular drugs: rifampin & rifabutin
• Tx for HIV: efavirenz & ritonavir
• Anti-convulasants: phenytoin, Carbamazepine, etc.
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
• Method Specific Effects
• Metabolic Changes
• 1.) In general:
• ↑ triglyceride, TCholesterol
• Estrogen - ↓LDL; ↑HDL,VLDL
• Some progestins – opposite
• 2.)Protein metabolism
• Estrogen -↑ hepatic prod’n of globulin  Increase
fibrinogen and clotting factors lead to thrombosis
• 3.) CHO metabolism = limited effects
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Method Specific Effects

– Cardiovascular Effects
• Permissible in well controlled uncomplicated
hypertension who are non-smokers, healthy, less
than 35 yo
• Alternative method: complicated hypertension
with end organ damage, stroke, smoker, migraine,
myocardial infarction, cardiovascular disease,
older age, diabetes, DVT, Pulmonary embolism
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Method Specific Effects

– Neoplasm
• COCs overall: NOT R/T to increased risk of CA
• Protective against ovarian and endometrial
cancer
• Increased risk for cervical dysplasia and
cancer
• Major studies show NO risk or small risk for
breast cancer
• Lower benign breast disease
VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES
• Transdermal Patch
• CHC
• Initiation same as COC
• Buttock, upper outer arm, lower
abdomen, upper torso
• Avoid the breast
• New patch weekly for 3 weeks
• 1 week patch free
– Eg: Ortho Evra
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Transvaginal Ring
– CHC
– Ethinyl estradiol and
progestin etonogestrel
– Inserted within 5 days of
menses
– 3 weeks use
– 1 week for withdrawal
bleeding
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Injectable Progestin Contraceptives

– depot medroxyprogesterone acetate (Depo-Provera), 150
mg every 3 months
– norethisterone enanthate, 200 mg every 2 months
– depo-subQ provera 104 - subcutaneous tissue of the
anterior thigh or abdomen every 3 months
– First 5 days of menses
– Prolonged anovulation can follow discontinuation
– Weight gain, loss of bone mineral density
 VERY EFFECTIVE CONTRACEPTION:
HORMONAL CONTRACEPTIVES

• Progestin Only Pills

– “Mini-pills”
• Not reliably inhibit ovulation
• Effectiveness depends on cervical mucus
thickening and endometrial atrophy
• Taken daily, same time every day
• If taken 4hours late supplemental form for
48hrs
• Contraindicated in women w/known breast CA or
pregnancy
 EFFECTIVE CONTRACEPTION:
BARRIER METHODS
• Male Condom
• Female Condom
• Diaphragm and Spermicide
• Cervical Cap
 LESS EFFECTIVE
CONTRACEPTION
• Spermicides
• Contraceptive sponge
 EMERGENCY CONTRACEPTION
• Decrease likelihood of unwanted
pregnancy
• COCS, POPs, Progesterone antagonists,
copper-containing IUDs

• Hormonal Emergency Contraception

– Yuzpe Method
• 100 ug of ethinyl estradiol and 0.5 mg
levonorgestrel in each of 2 doses, 12 hours apart
• Within 72 hours of intercourse to up to 120 hours

– POP
 EMERGENCY CONTRACEPTION

• Ulipristal acetate (Ella)

– Progesterone-receptor modulator
– 30 mg tablet OD

• IUD
– Inserted after 5 days
– failure rate only 0.1%
 PUERPERAL CONTRACEPTION

• Exclusively breastfeeding
– Ovulation in first 10 weeks unlikely
– Not reliable for non-regular BF

• Breastfeeding
– Progestin-only contraceptives – preferred
– IUD
 PUERPERAL CONTRACEPTION

– COC
• may reduce both rate and duration of milk
production
• Small quantities of hormone excreted in
breast but no adverse effect on infant
• Started after first 4 weeks – avoid venous
thromboembolism
 STERILIZATION

• Puerperal sterilization
– In conjunction with cesarean or vaginal delivery

• Non-puerperal tubal sterilization

– Time unrelated to recent pregnancy
– “Interval sterilization”
– Laparoscopically as outpatient surgery
– Hysteroscopic and Minilaparotomy
 STERILIZATION

– Puerperal sterilization
• Parkland Method
• Pomeroy Method
• Modified Pomeroy Technique
• Irving Technique
• Uchida Technique
• Kroener Fimbriectomy
Pomeroy Technique
Parkland Technique
Irving Technique
Salpingectomy
• Cumulative failure
rate is 18.5 per
1000 or 0.5%

• Salpingectomy –
lower pelvic
serous
carcinomas
 VASECTOMY
• The vas deferens
lumen is disrupted to
block passage of
sperm from the
testes
• Failure rate:
– 1st year: 9.4 per
1000
– 2,3,5 years: 11.4
per 1000