Contraceptionx 2 by liza tarca, md

Family Planning & Contraception

Liza Tarca-Cruz, MDDepartment of Obstetrics and Gynecology

Emilio Aguinaldo College of Medicine – Medical Center Manila

Family Planning or Contraception

“ a basic human right that benefits everyone”

Tabbakh

Goal

• Enable couples and individuals to choose – How many children they want– When to have them

• Best Achieve– Providing safe and effective methods– Information dissemination

Our Role as Medical Experts

“First do no harm”

(primum non nocere, Hippocrates ) 400 B.C

Philippines

Most Popular Contraception Method

Classification of Contraception

A.Natural or Fertility Awareness Method1. Standard Days Method

2. Calendar Rhythm Method

3. Symptoms Based Methoda. Temperature Rhythm Method

b. Cervical Mucus Rhythm Method

c. Sympthotermal Method

B.Lactation Amenorrhea

1.Artificial Method

1. Medical or Hormonal

2. Barrier

3. Permanent Sterilization

Fertility Awareness Method

• Natural Family Planning (NFP)– Sexual abstinence during fertile period

• Fertility Awareness Combined Method (FACM)– Using barrier method during the fertile time

Natural or Fertility Awareness Method

• Fertility Awareness–Fertile time of the menstrual cycle starts and ends–Ovum is fertilized 12 to 24 hours after ovulation–Ovulation may oocur 6 weeks post partum

•Periodic Abstinence• Natural Family Planning

Standard Days Method

• Avoid unprotected intercourse– Day 8 to 19

• Regular monthly cycles of 26 to 32 days• Use of cycle beads

Cycle Beads

Calendar Rhythm Method

• Counting the number of days in shortest and longest menstrual cycle during 6 to 12 month span

fertile timefertile time

Subtract 18 from the shortest cycle18 from the shortest cycle & 11 from the 11 from the longest cycle.longest cycle.

e.g : shortest cycle is 26 days & longest cycle is 34 days,

abstain from sexual relations from

Day 88 (26-18=8) through Day 2323 (34-11=23)

How to tell when you may be fertile ?

Chances of Pregnancy by Day of Intercourseday zero is ovulation

-5 -4 -3 -2 -1 0 1 2 3

0% 11% 15% 20% 26% 15% 9% 5% 0%

CALENDAR METHOD ( RHYTHM )

Symptom Base Method

• Billings Method – Cervical Mucus Method or Ovulation Method

• Cervical secretions or feeling of wetness

• Basal Body Temperature (BBT)– Slight body temperature rise after released of a fertilized egg– Temperature remains elevated until the start of next cycle

• Symptothermal Method– Combination of BBT and Billings Method

• 2 Day Method

Billings Method• Avoid unprotected sex

when secretions begin until 4 days after the peak day.

• PEAK DAY - last day where the secretions are clear, slippery, stretchy and wet

Billings Method

A = Intermediate type mucous B = Infertile type mucousC = Fertile type mucous

Basal Body Temperature

- Rise in temperature of 0.40F of morning BBT (OVULATION)- Abstain from unprotected intercourse from 1st day up to 3rd day after increase in BBT

Sympthotermal Method

• Change in cervical mucus ➡️ onset of fertility

• Increase in BBT ➡️ end of fertility

2 Day Method

• Presence of any type of secretion ➡️considered fertile for that day and the following day

Effectivity

Lactation Amenorrhea

• Temporary method• Ovulation is not possible during the first 10 weeks

postpartum• Effects of breastfeeding with fertility• 3 criteria for effectiveness

1. Monthly menstruation has not returned

2. Exclusive or nearly exclusive breastfeeding

3. Baby is less than 6 months old

Pathophysiology

• Prevents release of egg during ovulation

• Prevents release of ovulatory hormones

Artificial Method

A. Medical (Hormonal) a. Short Acting

1. Combined Oral Pills

2. Progestin Only Pills

b. Long Acting1. Combined Patch

2. Progesterone Implants

A. Injectables

B. Transvaginal Ring

1. Barrier Method1. Condom

2. Diaphragm & Cervical Cap

c. Spermicide cream & jelly

d. Sponge

e. Intra-uterine Device

C. Permanent Methodsa. Vasectomy

b. Tubal Ligation

Hormonal-Short Acting Combined Oral Contraceptive

Pills• Most widely used and most

successful reversible method of birth control

• Low doses of estrogen & progestin• Taken daily for 3 weeks and omitted

for 1 week during which there is withdrawal uterine bleeding

• Ethinyl Estradiol, Mestranol)• 19 Nortestosterone derivatives• Types• MONOPHASIC – type & dosage of

hormone remains constant during the 21 days

• MULTIPHASIC – dose varies during cycle

Mechanism of Action COC

Mechanism of Action COC

• Progestin– Prevents ovulation by suppressing LH– Thickened mucus ➡️ retards sperm passage– Endometrium ➡️ unfavorable for implantation

• Estrogen– Prevents ovulation by suppressing FSH– Stabilize endometrium ➡️ prevents breakthrough

bleeding

Pill Usage

Missed a pill? What to do?

Combined Oral Contraceptive Pills

Drug Interaction• Phenytoin & Rifampin ➡️ increase breakthrough bleeding &

reduce contraceptive effectiveness• Ascorbic Acid ➡️ competes for active sulfate in the intestinal

wall & increases the bioavailability of ethinyl estradiol results to breakthrough bleeding

• Ovulation – occurs 3 months after discontinuance• Postpill amenorrhea – if COC are stopped

Combined Oral Contraceptive PillsBeneficial Effects• Increase bone density• Decrease risk of ectopic pregnancy• Fewer premenstrual complaints• Reduction on various benign breast disease• Improvement of acne• Decrease incidence & severity of acute salphingitis• Reduce menstrual blood loss & anemia• Improved dysmenorrhea for endometriosis• Decreased risk of endometrial & ovarian cancer• Inhibition of hirsutism progression• Prevention of atherogenesis• Improvement in rheumatoid arthritis

Combined Oral Contraceptive PillsAdverse Effects• T4 and thyroid binding proteins are elevated• Plasma cortisol are also increased• Increase serum levels of triglycerides and total cholesterol• Decrease testoterone• Increase risk of cervical dysplasia and cancer• Lower plasma level of ascorbic acid, folic acid, vitamin B6, B12,

niacin, riboflavin and zinc• Increase risk of thromboembolism if used with CVD patient, > 35

years old and smokers • Increase risk of Chlamydia trachomatis infection• Cervical mucorrhea

Combined Oral Contraceptive Pills

CONTRAINDICATED

• Thrombophlebitis, thromboembolic disease, DVT

• CVD, CAD

• Thrombogenic cardiac valvulopathies & arrythmias

• DM w/ vascular involvement

• Uncontrolled HPN

• Breast, endometrial, hepatic CA

• AUB

• Pregnancy

• Cholestatic jaundice

• Major surgery with prolonged immobilization

Hormonal-Short Acting

Progestin Only Pills• Low dose progestin• Safe for breastfeeding mothers & women who

could not use estrogen like with CVD• Minipills or POPs• Do not inhibit ovulation• Thickens the cervical mucus ➡️ block sperm• Effects on endometrium• Disrupting menstrual cycle by preventing

release of fertilized eggs• Taken same time of the day for maximal

effectiveness• If taken 4 hours late ➡️ BACK UP

CONTRACEPTION x 48 hours

Progestin Only Pills

Benefits • Minimal effect on CHO

metabolism & coagulation• Do not cause or

exacerbates HPN

Disadvantages• Contraception failure• Ectopic pregnancy• Irregular uterine bleeding

– Amenorrhea, spotting, breakthrough bleeding, menorrhagia)

• Functional ovarian cyst

Progestin Only Pills

Contraindicated• Unexplained bleeding• Breast cancer• Liver tumor• Pregnancy• Acute liver disease• Carbamazepines, Phenobarbital, Phenytoin, Rifampicin,

Griseofulvin

Hormonal-Long Acting

Combined Patch • Continuously release progestin &

estrogen directly through the skin to the blood stream

• A new patch is worn every week for 3 consecutive weeks

• No patch on the 4th week so menstruation ensues

• Works primarily by preventing release of ovulated eggs

• 150ug progestin norelgestrinon + 20ug ethinyl estradiol

• First 2 cycle – dysmenorrhea, breast tenderness & breakthrough bleeding

Where to apply?


Intravaginal or Transvaginal Hormonal Contraceptive Ring

• Flexible polymer ring has an outer diameter 54mm & 4mm cross section

• Releases Ethinyl estradiol 15ug and Etonogestrel 120ug/day

• Inhibits ovulation• Ring is placed w/in 5 days of

onset of menses & removed after 3 weeks of use for 1 week to allow w/drawal bleeding

• Ring replaced w/in 3 hours within intercourse

• Complications: vaginitis, ring related events, leukorrhea


• How to insert/use transvaginal ring


Implants• Small rods or capsules placed

under the skin of a woman’s upper arm (subdermal)

• 3 to 7 years effectiveness• Safe for breastfeeding

beginning 6 weeks post partum• Thickens the cervical mucus

& delay release of eggs from the ovary

• Progestin suppress ovulation• NORPLANT – levonorgestrel

(6)• JADELLE (2)• IMPLANON (1) – 68mg

Etonogestrel

Implants


Injectable Medroxyprogesterone Acetate/Estradiol Cypionate

• Lunelle• 1 injection monthly• Inhibits ovulation• Supress endometrial

proliferation• Estradiol reach peak level 3-

4 days post injection & decline leading to w/drawal bleeding to 20-25days after injection


Benefits• Returns to fertility after

discontinuance• Less breakthrough

bleeding• Amenorrhea more frequent

Disadvantage• Decrease lactation• Weight gain


Progestin Only Injectables

• DMPA – depot medroxyprogesterone acetate

• The “shot” or “jab (150mg every 3 months)

• Depo-provera, Depo, Megestron & Petogen

• NET EN – Norethindrone Enanthate

• Noristerat, Syngestal (200mg every 2 months)

• Intramuscular or subcutaneous (upper outer quadrant buttocks)

• Inhibit ovulation, increase viscosity of cervical mucus, endometrium unfavorable for implantation


Benefits• Long duration of action• Minimal to no impaiment of

lactation• Decrease ovarian and

endoetrial cancer

Disadvantage• Irregular menstrual bleeding• Prolonged anovulation after

discontinuance• Delayed fertility resumption• Menses may not resume up to 1

year• Increase risk cervical CA• Breast tenderness• Weight gain• Decrease bone density - REVERSIBLE


• Contraindication– Thromboembolism– Stroke– Cerebro/Cardio VD– Pregnancy– Undiagnosed vaginal

bleeding– Breast CA– Liver Disease

Barrier Method-Condom

•Prevents pregnancy & STI•Easy to use• Practical

MALE CONDOM

• Failure rate: 3 or 4 couple-years of exposure

• Lubricants used should be water based– Oil based products can destroy latex condoms

MALE CONDOM

• Maximal effectiveness – condom must be used with every coital act– place before contact of the penis with the vagina– Withdrawal must occur with the penis still erect– The base of the condom must be held during

withdrawal– Either an intravaginal spermicide or a condom

lubricated with spermicide should be employed

Proper USE of MALE CONDOM

FEMALE CONDOM

• Pregnancy rate higher than male condom• Polyurethane sheath with one flexible

polyurethane ring at each end–Open ring remains outside the vagina–Closed internal ring is fitted under symphysis

DO NOT USE SIMULTANEOUS WITH MALE CONDOM SINCE FRICTION LEADS TO SLIPPING, TEARING & DISPLACEMENT

Proper USE of FEMALE CONDOM

Barrier Method-Diaphragm

•Soft latex cup that covers the cervix•Spring along the rim to keep it in place•Used with spermicidal creams/jelly or sponge for effectiveness•Inserted few hours before intercourse ➡️ add spermicide•Should not be remove <6hrs, and not stay >6hours ➡️ TSS•Increase rate UTI

Barrier Method-Cervical Cap

•Soft, deep, latex or rubber cup that covers the cervix•Prevents the sperm to enter the cervix•Best used with spermicides•Compatible to diaphragm

Barrier Method-Spermicides• Physical barrier to sperm penetration• Chemical spermicidal - sperm killing substance inserted

deep into the vagina, near the cervix prior to sexual intercourse

• Nonoxynol 9 – most popular• benzalkonium chloride, chlorhexidine, menfegol, octoxynol-9, and

sodium docusate• Duration of Efficacy: 1 hour• Non teratogenic

Barrier Method-Spermicides

• foaming tablets, melting or foaming suppositories, cans of pressurized foam, melting film, jelly, and cream

– Jellies, creams, and foam from cans can be used alone, with a diaphragm, or with condoms.

– Films, suppositories, foaming tablets, or foaming suppositories can be used alone or with condoms

• causing the membrane of sperm cells to break, killing them or slowing their movement

Barrier Method-Sponge • Plastic contains spermicides

• Inserted 24 hours prior to intercourse, removed 6 hours post intercourse

• Moistened with water and inserted into the vagina so that it rests against the cervix

• Used only once

• not widely available

• Less effective

• Nonoxynol 9 impregnated disc– 2.5cm thick, 5.5cm wide

• May cause irritation and

vaginitis

Lea’s Shield

• Reusable, washable barrier made of silicone

• Placed against the cervix • Inserted any time prior to

intercourse and must be left in place for at least 8 hours afterwards

Barrier Method-IUD

-Insert near end of normal menses-w/hold insertion for at least 8 weeks post partum-RANDALL STONE CLAMP

Barrier Method-IUD

• copper-bearing intrauterine device– small, flexible plastic frame with copper sleeves or wire around it

• trained health care provider inserts it into a woman’s uterus through her vagina and cervix ➡️ reduce pelvic infection

• causing a chemical change that damages sperm and egg before they can meet ➡️ interfere implantation

• Local inflammatory response (uterus) ➡️ Lysosomal Activation & Inflammatory Actions ➡️ SPERMICIDAL

• Effectiveness: Equivalent to BTL

Barrier Method-IUD

• Paragard T 380A– Copper– 10 years– Chemically inert

• Mirena– Levonogrestel– 5 years– Reduce menstrual loss– Treat menorrhagia– Reduce dysmenorrhea, PID

Chemically inert – nonabsorbable material (polyethylene) impregnated in Barium Sulfate (for radioopacity)

Chemically active – continuous elution of copper or progestational agent

Barrier Method - IUD

IUD Insertion

Barrier Method-IUD

• Disadvantages– Uterine perforation– Dysmennorhea– AUB– Expulsion– Iron deficiency anemia– Infection

NEVER ASSUME THAT THE DEVICE HAS BEEN EXPELLED UNLESS IT WAS SEEN!

Barrier Method-IUD

• Benefit– Reversible method– Fertility not impaired– No increase risk of genital tract or breast neoplasia– No loss of bone mineral density and weight gain

Barrier Method-IUD• Contraindicated

– Pregnancy– Abnormal uterus– Acute PID– Postpartum endometritis or infected abortion (past 3 months)– Uterine or cervix malignancy– Abnormal papsmear– AUB– Untreated cervicitis, vaginitis, bacterial vaginosis– Multiple sexual partners– Susceptible infections, genital actinomyosis– History of ectopic pregnancy– IUD not removed

– Copper ➡️Wilson’s Dse., Copper Allergy– Mirena ➡️ breast CA, acute liver disease, hypersensitivity

Emergency Contraception

• The Morning-After Pill– diethylstilbestrol (DES)

• Yuzpe method (1974)– 100 g ethinyl estradiol

plus 1.0 mg dL-norgestrel

• Plan B (1999)– first progestin-only

emergency contraceptive

Emergency Contraception• Yuzpe

– COC + 2 POP– 2 tabs w/in 72hrs then 12hrs after

• POP– 1st dose w/in 72hrs then 12hrs after

• Ovrette– 20 pills w/in 72hrs then 12hrs after

• Copper IUD– Postcoital contraception– Inserted up to 5 days after

unprotected intercourse

• Misoprostol/Epostane– Block progesterone production

– Interfere w/ progesterone action– Menstruation – implantation

prevented

• Inhibition or delay ovulation

• Alteration of endometrium, sperm penetartion, tubal motility

• SE: nausea/vomiting – estrogen related

• If (+) vomiting w/in 2hours – repeat dose

Vasectomy

• Meant to be permanent• Use another method for the first

3 months, until the vasectomy starts to work (20 ejaculations)

• Very effective after 3 months but not 100%

• Safe, simple, convenient surgery • No effect on sexual ability or

feelings

• Works by closing off each vas deferens, keeping sperm out of semen

• Semen is ejaculated, but it cannot cause pregnancy

Vasectomy

• One of the most effective methods but carries a small risk of failure

– If semen is not examined 3 months after the procedure to see if it still contains sperm, pregnancy rates are about 2 to 3 per 100 women over the first year after their partners have had a vasectomy.

– If semen was examined after vasectomy, less than 1 pregnancy per 100 women over the first year after their partners have had vasectomies (2 per 1,000).

Vasectomy

Through a puncture or small incision in the scrotum, the provider locates each of the 2 tubes that carries sperm to the penis (vas deferens) and cuts or blocks it by cutting and tying it closed or by applying heat or electricity (cautery).

Tubal Ligation

• Female sterilization• Permanent• Effectiveness varies slightly

depending on how the tubes are blocked

• Fertility does not return because sterilization generally cannot be stopped or reversed

• fallopian tubes are blocked or cut Eggs released from the ovaries cannot move down the tubes do not meet sperm

Tubal Ligation

• Reversal surgery is difficult, expensive, and not readily available.– often does not lead to pregnancy

Tubal Ligation

• 2 surgical approachesMinilaparotomy - making a small incision in the abdomen. The fallopian tubes are brought to the incision to be cut or blocked.

Laparoscopy - inserting a long thin tube with a lens in it into the abdomen through a small incision. This laparoscope enables the doctor to see and block or cut the fallopian tubes in the abdomen

Conditions & Suggested Contraception

• Migraine POP• Lactation POP (up to 6 months postpartum)

intermittent breastfeeding – use effective contraception as soon as 3 weeks postpartum

• CVD, HPN, smoker POP• > 35 y.o IUD, COC, DMPA

Condition and Unsafe MethodCondition Methods Not Advised

Smoke cigarettes and also age 35 or older

Combined oral contraceptive pills (COCs). If you smoke heavily, monthly injectables.

Known high blood pressure COCs, monthly injectables. If severe high blood pressure, 2- and 3-month injectables.

Fully or nearly fully breastfeeding in first 6 months

Breastfeeding in first 6 weeks

First 21 days after childbirth, not breastfeeding

COCs, monthly injectables.2- and 3-month injectables,

implants, progestin-only pills (POPs).COCs, monthly injectables.

Wait until 6 weeks after childbirth to fit diaphragm correctly.

Certain uncommon serious diseases of the heart, blood vessels, or liver, or breast cancer.

COCs, injectables, POPs, implants. Ask your provider.

Condition and Unsafe MethodCondition Methods Not Advised

Migraine headaches (a type of severe

headache) and also age 35 or older.

COCs, monthly injectables. Ask your provider.

Gall bladder disease COCs. Ask your provider.Certain uncommon

conditions of female organsIUD. Ask your provider.

Sexually transmitted infections of the cervix, very high individual risk of getting these infections, pelvic inflammatory disease (PID), or untreated AIDS

IUD. Use condoms even if also using another method.

Women with HIV, including women with AIDS and those on treatment, can generally use any family planning method they choose.

Known pregnancy No method needed.

Contraceptionx 2 by liza tarca, md

Health & Medicine

Transcript of Contraceptionx 2 by liza tarca, md