Dr.Tarig Mahmoud Ahmed

MD SUDAN

HAIL UNIVERSITY KSA

the practice of controlling the number of children one

has and the intervals between their births,

particularly by means of contraception or voluntary

sterilization.

Combined hormonal contraceptio

The pill

Patches

The vaginal ring

Progestogen-only preparations

Progestogen-only pills

Injectables

Subdermal implants

Hormonal emergency contraception

Intrauterine contraception

Copper intrauterine device (IUD)

Hormone-releasing intrauterine system (IUS)

Barrier methods

Condoms

Female barriers

Coitus interruptus

Natural family planning

Sterilization

Female sterilization

Vasectomy

The effectiveness of a method depends on two

factors:

1 )how it works;

2) how easy it is to use.

failure caused mainly due to poor use (user failure)

rather than an intrinsic failure of the method

itself.

Method of contraception Failure rate per 100

woman years

Combined oral contraceptive pill 0.1–1

Progestogen-only pill 1–3

Depo-Provera® 0.1–2

Implanon® 0.1

Copper IUD 1–2

Method of contraception Failure rate per 100

woman years

Mirena® 0.5

Male condom 2–5

Diaphragm 1–15

Natural family planning 2–3

Vasectomy 0.02

Female sterilization 0.13

Studies looking at pill use report nearly

half of all women missing at least one pill per packet and a

quarter missing two pills.

Women are often quick to stop contraception because of

perceived side effects, such as weight gain or mood change.

It contains a combination of two hormones:

synthetic oestrogen and a progestogen.

Most brands contain 21 pills; one pill to be taken

daily, followed by a 7-day pill-free interval (the

traditional 21/7 model). There are also some

everyday (ED) preparations that include seven

placebo pills that are taken instead of having a

pill-free interval.

Mode of action

Inhibition of ovulation :

Both oestrogen and progestogen suppress the release of (FSH) &(LH),which prevents follicular development within the ovary and therefore ovulation.

Peripheral effects :

making the endometrium atrophic and hostile to implantation and altering cervical mucus to prevent sperm ascending into the uterine cavity.

absolute contraindications:

1-Breastfeeding <6 weeks postpartum

2-Smoking ≥15 cigarettes/day and age ≥35

3-Multiple risk factors for cardiovascular disease

4-Hypertension: systolic pressure ≥160 or diastolic ≥100

mmHg

5-Hypertension with vascular disease

6-Current or history of deep-vein thrombosis/pulmonary

embolism

7-Major surgery with prolonged immobilization

8-Known thrombogenic mutations

9-Current or history of ischaemic heart disease

10-Current or history of stroke

11-Complicated valvular heart disease

12-Migraine with aura

13-Migraine without aura and age ≥35 (continuation)

14-Current breast cancer

15-Diabetes for ≥20 years or with severe vascular disease or

with severe nephropathy,retinopathy or neuropathy

16-Active viral hepatitis

17-Severe cirrhosis

18-Benign or malignant liver

relative contraindications:

1-Multiple risk factors for arterial disease

2-Hypertension: systolic blood pressure 140–159 or diastolic

pressure 90–99 mmHg,

or adequately treated to below 140/90 mmHg

3-Some known hyperlipidaemias

4-Diabetes mellitus with vascular disease

5-Smoking (<15 cigarettes/day) and age ≥35 years

6-Obesity

7-Migraine, even without aura, and age ≥35 years

8-Breast cancer with >5 years without recurrence

9-Breastfeeding until six months postpartum

10-Postpartum and not breastfeeding until 21 days after

childbirth

11-Current or medically treated gallbladder disease

12-History of cholestasis related to combined oral

contraceptives

13-Mild cirrhosis

14-Taking rifampicin (rifampin) or certain anticonvulsants

CNS: Depressed mood, Mood swings, Headache

Loss of libido.

GIT: Nausea, weight gain & Bloatedness.

Reproductive system : Breakthrough bleeding

&Increased vaginal discharge

Breasts :Breast pain & enlarged breasts.

Miscellaneous :Chloasma (facial

pigmentation),Fluid retention & Change in

contact lens.

• 5 per 100 000 for normal population;

• 15 per 100 000 for users of second-generation

COC

• 30 per 100 000 for users of third-generation

COC

• 60 per 100 000 for pregnant women.

This can occur with enzyme-inducing agents, such as

some anti-epileptic drugs. Higher dose estrogen may

need to be prescribed.

Some broad-spectrum antibiotics can alter

intestinal absorption of COC and reduce its efficacy.

Additional contraceptive measures should therefore be

recommended during antibiotic therapy and for 1

week thereafter.

A contraceptive transdermal patch containing

oestrogen and progestogen and releases

norelgestromin 150 mg and ethinylestradiol 20 mg

per 24 hours.

Patches are applied weekly for 3 weeks, after

which there is a patch-free week.

Contraceptive patches have the same risks and

benefits as COC and, although they are relatively

more expensive, may have better compliance.

It is made of latex-free plastic and has a

diameter of 54 mm. It releases a daily dose

of ethinyl estradiol 15 μg and etonorgestrel

120 μg.

The ring is worn for 21 days and removed for

7 days, during which time a withdrawal

bleed occurs.

Insertion and removal of the ring is easy and it

does not need to fit in any special place in the

vagina.

The cycle control is excellent and probably

better than with COC.

As with combined patches, the vaginal ring has

the same risks and benefits as COC but is

more expensive.

All progestogen-only methods work by a local

effect on cervical mucus (making it hostile

toascending sperm) and on the endometrium

(making it thin and atrophic), thereby preventing

implantation and sperm transport.

The higher dose progestogen only methods will also

act centrally and inhibit ovulation, making them

highly effective.

The common side effects of progestogen-only

methods include:

erratic or absent menstrual bleeding;

simple, functional ovarian cysts;

breast tenderness;

acne.

they contain the second-generation

progestogen norethisterone or norgestrel (or

their derivatives) and the third-generation

progestogen desogestrel.

It is taken every day without a break.

If the POP fails, there is a slightly higher risk

of ectopic pregnancy.

Particular indications for the POP include:

• breastfeeding;

• older age;

• cardiovascular risk factors, for example

high blood pressure, smoking or diabetes.

Two injectable progestogens are marketed :

(1) depot medroxyprogesterone acetate 150 mg (Depo

Provera/DMPA);

(2) norethisterone enanthate 200 mg (Noristerat).

Depo-Provera is highly effective and it is given by

deep intramuscular injection.

Most women choose Depo-Provera and each

injection lasts for 12 weeks with a 2-week grace

period thereafter.

weight gain of around 2–3 kg in the first year of

use;

delay in return of fertility – it may take around six

months longer to conceive compared to a

womanwho stops COC;

persistently irregular periods; most women

become amenorrhoeic.

Implanon consists of a single silastic rod that is

inserted subdermally under local anaesthetic into

the upper arm .

It releases the progestogen etonogestrel 25–70 mg

daily.

It lasts for three years and thereafter can be easily

removed and a further implant inserted if

requested.

Implanon is useful for women who have difficulty

remembering to take a pill

There is a rapid return of fertility when it is removed.

Irregular bleeding is very common with Implanonand is the major reason for early discontinuation.

Healthcare professionals need special training for Implanon insertion and removal.

Most copper IUDs are licensed for ten years of

use, although the small devices may only be for

five years.

The modern ‘banded’ device has copper on the

stem and copper sleeves on the arms.

They cause much less menstrual disruption.

A copper IUD can be inserted for emergency

contraception and is highly effective up to 5 days

after the episode of unprotected intercourse.

Mirena licensed for five years.

The Mirena has a capsule containing

levonorgestrel around its stem which releases

adaily dose of 20 μg of hormone.

It is associated with a dramatic reduction in

menstrual blood loss and is licensed for

contraception.

current STI or PID, including post-abortion and

following childbirth;

malignant trophoblastic disease;

unexplained vaginal bleeding (before assessment);

endometrial and cervical cancer (until assessed

and treated);

known malformation of the uterus or distortion of

the cavity , eg (fibroids);

copper allergy (but could use a Mirena).

Male condoms are usually made of latex rubber

varying sizes and shapes.

They have been heavily promoted to prevent the

spread of STIs , particularly HIV.

The diaphragm iscommon female barrier used.

They should be used in conjunction with a

spermicidal cream or gel.

Diaphragms are inserted immediately prior to

intercourse and should be removed no earlier than

6 hours later.

Although not strictly speaking a barrier

method,withdrawal, or coitus interruptus, is a

widespread practice and obviously does not require

any medical advice or supplies.

The penis is removed from the vagina immediately

before ejaculation takes place.

It abstaining from intercourse during the fertile

period of the month.

The fertile period is calculated by various

techniques, such as:

(1)changes in basal body temperature;

(2) changes in cervical mucus;

(3) tracking cycle days;

(4)combined approaches.

The lactational amenorrhoea method (LAM) is used

by fully breastfeeding mothers. During the first six

months of infant life, full breastfeeding gives more

than 98 per cent contraceptive protection.

Female sterilization and male vasectomy are permanent methods of contraception and are highly effective.

Vasectomy is easier, cheaper and slightly more effective than female sterilization.

Technically, both female sterilization and vasectomy can be reversed, with subsequent pregnancy rates of about 25 per cent.