CONTRACEPTION

Supervised by: Prepared by:

Dr. Fadia Jasim Dua Mahdi Hajer Falah
Noor Abbas Youshia Emad
Amena Adel Abbas Fadhil
Karam Marwan Sunner Amer
 CASE

28 years old women married for 4 years came asking

for advice regarding the methods of contraception
and the risk of using it what will you tell her?
 ANSWER
Contraception (birth control) prevents pregnancy by interfering with
the normal process of ovulation, fertilization and implantation.
There are different kinds of birth control that act at different points in
the process.

The Characteristics of Ideal contraceptives:

1. Highly effective 2 . No side effect 3 . Cheap
4 . Independent of intercourse and requires no regular action on
the part of the user
5 . Non contraceptive benefits
6 . acceptable to all cultures and religions
7 . Easily distributed & administered by non-healthcare personnel
FAILURE RATE
 CASE
A 25 year old women attends your family planning clinic,
She has never used the COCP and is considering starting
it. She wants to know the benefits and risks involved.
What is your advice ?
 Combined Hormonal Contraception

Content:
It consists of synthetic estrogen & progesterone.
 It’s easy & offers a very high degree of protection.
 It should be taken regularly at a roughly the same time each day.

Mechanism of action:
1. Inhibit ovulation
2. Peripheral effect
 Regimens

Monophasic : contains standard Daily Dose

Biphasic , Triphasic , Quadriphasic

 Most of the brands have : 21/7 Model , contain 21 pills , followed

by free interval for 7 days
 Other contain placebo pills instead of the free interval
 Other models 24/4 , 84/7 and 365.
 Side Effects
Major side effects
1. Venous thromboembolism
2. Arterial disease
3. Breast cancer
4. Drug interaction
Other side effects
1. Central nervous system (Mood
changes, loss of libido)
2. Gastrointestinal (Nausea, weight
gain)
3. Reproductive system
(Breakthrough bleeding)
4. Breast (Breast pain)
5. Miscellaneous (Fluid retention)
 CASE

A 24 year old female, who has been on the COPCP for the
last 3 years presents to you saying that she has missed two
pills in succession. Justify the advice you will give her.
 Missed Pills

Three or more 30-

One or two 30-35mg /one
35mg/>2 20mg
20mg ethinylestradiol pills
ethinylestradiol pills

Take the missed Take the missed

pill ASAP pill ASAP

- Continue taking the

remaining pills daily.
- NO need for additional
contraceptive protection.
-Continue taking the remaining
pills daily.
- Advised to use condoms or
abstain from sex until she has
taken pills for 7 days in a row.
• In addition

 If pills are missed in week (1) emergency contraception if

unprotected sex.
 If pills are missed in week (3) she should finish the pills in her
current pack and start a new in the next day.
 CASE

A 22-yr old female seeking for your advice regarding the

probable method of contraception. She has migraine, she
is not breast feeding, her body weight is 65 kg, doesn’t
want a long period of infertility and wants an easy method.
What would you prefer to describe to her ?
 Ortho Evra (the patch)
Transdermal contraceptive patch that contains estrogen and progesterone.
Content: It delivers in the blood stream 20µg of ethinyl estradiol and 150µg of
norelgestromin.
The patch is thin, flexible, 2-inch square that is worn on the body.
Mechanism of action: The increased hormone level caused by the patch stop
the ovaries from releasing an egg each month. 99% effective.
Use: A new patch is applied each week for three weeks (21 total days). Week
Four is patch-free. Withdrawal bleeding is expected during this time.

Every new patch should be applied on the same day of the week.
 HOW TO APPLY ORTHO EVRA ?
A woman applies her first patch onto her upper outer arm,
buttocks, abdomen or thigh on either the first day of
her menstrual cycle (day 1) or on the first Sunday following that
day, whichever she prefers.
 Side Effects

 Nausea and/or vomiting

 Application site reaction
 Breast discomfort
 Engorgement or pain
 Headache
 Emotional liability
 Combined hormonal vaginal rings (NuvaRing)

It’s made of latex-free plastic & has a

diameter of 54mm. It releases a daily
dose of ethinyl estradiol 15mg &
etonorgestrel 120 mg. The ring is worn
for 21 days & removed for 7 days,
during which time withdrawal bleed
occurs. Insertion and removal of the
ring is easy and does not need to fit
in special place in the vagina.
Advantages:
It’s easy, cost-effective, acceptable ,
tolerable, excellent cycle-control
and better than COC.
 Side Effects

 Leucorrhea
 Vaginitis
 Expulsions
 Vaginal discomfort with foreign body
sensation and coital problems
 CASE
A 38 year old female, gravida 3, suffered preeclampsia in her latest
pregnancy and now her blood pressure is constantly approximately
140/90mmHg on multiple visits and monitoring. She came asking for
your advice regarding the probable method of contraception.
Knowing she is a smoker and has a family history of breast cancer
what will be your advice to her ?
 ANSWER
Progestrogen-only contraception

The current methods used are:

1. Progestogen-only pill, or mini-pill.
2. Subdermal implant (implanon).
3. Injectable (depo-provera, noristeral).
4. Hormone-releasing intrauterine system (mirena).
 Progestogen-only pills (pop)

Mechanism: They act centrally (inhibiting ovulation) & peripherally

(preventing serm transport & implantation).

Particular indications:
1. Breast feeding
2. Older age
3. Cardiovascular risk factors including:
• Hypertension
• Diabetic women
• Smokers
The common side effects are:
1. Erratic or absent menstrual bleeding
2. Simple, functional ovarian cyst
3. Breast tenderness
4. Acne
They are taken everyday without a break, ideal for
women at times of lower infertility because the failure
rates in POP is greater than that in COC , with a higher risk
of ectopic pregnancy.
 Injectable Progestogens
Depot medroxyprogesterone acetate(Depo-provera)150mg each
injection lasts 12 weeks.
Route: given by IM injection.

Advantages
• Improve premenstrual syndrome
• Treat painful and heavy periods
• Non-compliant patients
Disadvantages
• Weight gain
• Delay in fertility for 6 m or longer
• Irregular periods or mostly amenorrhea
Subdermal Implants
 CASE
A 34-year-old female, G4P3A1, expresses her wishes to have
a contraceptive method in the form of implants. She has no
desire for future pregnancies, And wants to know the failure
rate and side effects for using such method?
 The birth control implant is a tiny, thin rod about the size of
a matchstick. The implant releases hormones into the body
to prevent pregnancy.
 What is Norplant?

The Norplant contraceptive is a long-acting, low-dose, progestin

only contraceptive system for women. The drug is delivered by
means of 6 silastic capsules implanted sub dermally in the
woman’s arm employing a minor surgical technique. It is highly
effective and highly reversible.
 Previously available in 6 capsules (36 mg each) Norplant-2 rod system
comprises 2 silastic rods containing a total of 140 mg of levonorgestrel (70
mg/rod). The rods are implanted subdermally in the women’s arm employing
a minor surgical technique.
 Time: Within 7 days after the onset of menstruation or immediately after
abortion or first trimester MTP. The implants become effective within 24 hours of
placement.
 Mechanism of action is mainly local on cervical mucous and endometrium but
it also inhibits ovulation in about 50% of the cycles.

 Failure rate: Less than 0.5 per hundred women years.

 Contraindications: Anticoagulant therapy, undiagnosed, abnormal uterine

bleeding, known or suspected pregnancy, hemorrhagic diathesis, liver
diseases.
 Side effects: Bleeding disorders, amenorrhoea, nausea,
loss of appetite, dizziness, headache, changes in libido,
depression, acne, infection at implant site.
 Removal: Implants work up to 5 years, after that they
should be removed employing a minor surgical
technique.
 What is Implanon ?

Implanon It is newer implant containing

68mg, in the form of a single rod.
Its duration of use is 3 years & its efficacy is
excellent, acting primarily by ovulation
inhibition.
It has an advantage in diabetics that is the
avoidance of estrogens use.
Disadvantages include altering bleeding
patterns, frequent bleeding or spotting
 CASE
A 30-year old woman came to the clinic seeking advice on
contraceptive method that have long term effect and
independent of intercourse what will you advice her ?
 Intrauterine contraception

1. Plastic inert devices

2. Copper-bear devices
They have toxic effect on both sperm and eggs,
induce an inflammatory response in the endometrium
which prevent implantation.
 Contraindication

 Current STD or PID

 Previous ectopic pregnancy
 Malformation or fibroid in uterus
 Malignant trophoblastic disease or
endometrial or cervical ca
 Unexplained vaginal bleeding
 Previous IUD not removed
 Copper allergy
 Side Effects

 Increased menstrual blood loss

 Increased dysmenorrhoea
 Risk of PID in first few weeks
 High risk of ectopic pregnancy if failed
 Risk of perforation mainly at insertion
3 . Hormone releasing intrauterine system
It has a Capsule containing levonorgestrel relaesed in
daily dose of 20 micro-gm.
Mechanism of action: It prevents pregnancy by its
hormonal effect on cervical mucus, endometrium, tubes.
 Advantages
Highly effective and protect against PID
Reduction of blood loss
Part of HRT
 Disadvantages
Spotting and irregular bleeding plus the
progestogenic side effects
 Emergency contraception

A back-up method that is considered if:

1. Unprotected intercourse has occurred

2. Failure of barrier method
3. If hormonal contraception has been
forgotten
 TYPES
1 . Hormonal EC:

A . Levonorgestrel singles dose 1.5mg, within 72 hours, it disrupt

ovulation /corpus luteal function
B . Progesteron receptor modulater, used within 120 hours

2 . Intrauterine device EC:

Inserted within 5 days , it prevents implantation and copper ions
has embryotoxic effects, Mirena is not effective for EC.
 Barrier method of contraception

 Spermicides: Used with other barrier method like Female

diaphragm which protect from pelvic infection but increase
UTI risk
 Withdrawal coitus interruptus (Not reliable)

 Natural family planning: No intercourse during the fertile

period

 Lactation amenorrhea (within 6 m.)

 “
“Male sterilization is safer and more
effective than female.”
How you justify the statement and council a couple who
want to know about this method ?
1 . Male sterilization in the form of vasectomy is procedure which involve
division of each vas with diathermy and the female often in the form of tube
blockage by (clips, ligation, diathermy)

2 . It’s performed under local anesthesia in male while require general in

females.
3 . Both methods are associated with failure rates but in male sterilization with
vasectomy its 10 times less likely.
4 . Female sterilization s associated with a higher risk of ectopic pregnancy in
case of failure.
5 . Male who undergo vasectomy should use alternative method of
contraception after the procedure until 2 consecutive semen analysis show
azospermia 2-4 weeks apart with the first being 8 w after surgery.

6 . Small risk of chronic testicular pain in vasectomy

Thanks!