Fertility control

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Contraception:Classification:Hormonal contraception:

 Combined oral contraceptionCombined hormonal patchesProgestogen-only preparation-Progestogen-only pills-injectables-subdermal implants

Intrauterine contraceptionCopper intrauterine deviceHormone-releasing intrauterine system(IUS)Barrier methodsCondomsFemale barriersCoitus interruptusNatural family planningEmergency contraceptionSterilizationFemale sterilizationVasectomy

The number of failures per 100 women year(HWY): is the number of pregnancies if 100 women were to use the method for 1 year

One- method failure is either to imperfect use (user failure)- most common-, or to intrinsic method failure.

 Contraceptive method failure rate

per HWYCOCP 0.1-1POP 1-3Depo provera 0.1-2 Implanon 0Copper bearing IUD 1-2LNIUS 0.5Male condom 2-5Female diaphragm 1-15Persona 6Natural family planning 2-3Vasectomy 0.02Female sterilization 0.13 

HORMONAL CONTRACEPTIVE METHODSCOMBINED ESTROGEN AND PROGESTIN METHODSOral Contraceptive Pills (OCPs)

FormulationsModern preparations contain ethinyl estradiol in a daily

dose of between 20-35 mcg, higher doses of estrogen are strongly linked to increased both arterial and venous thrumbosis,

Progestogens in the pills are classed as second (norethisterone acetate or levonorgestrel) or third generation (gestoden, desogestrel, norgestimate) or antimineralocorticoides and antiandrogenic(drospirenone).

Monophasic pills have fixed estrogen/progesterone doseBiphasic and triphasic preparations have 2 or 3

incremental doses of estrogen and progesterone.They either contain21 pills with 7 days pill-free periodOr ED-every day preparations- that include 7 placebo pills

mechanism of contraceptionOral contraceptives place the body in a

pseudo-pregnancy state by interfering with the pulsatile release of follicle-stimulating

hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. This pseudo-pregnancy state suppresses ovulation

2- thickening the cervical mucus to render it less penetrable by sperm and

3-changing the endometrium to make it unsuitable for implantation.

Decrease risk of serious diseasesOvarian cancerEndometrial cancerEctopic pregnancy (combination pills only)Severe anemiaPelvic inflammatory diseaseImprove quality-of-life problems Iron-deficiency anemiaDysmenorrheaFunctional ovarian cystsBenign breast diseaseOsteoporosis (increased bone density)Rheumatoid arthritisTreat/manage many disordersDysfunctional uterine bleedingControl of bleeding in bleeding disorders and anovulationDysmenorrheaEndometriosisAcne/hirsutismPremenstrual syndrome (PMS)

Contraindications to Combination Estrogen-Progesterone Contraceptives Absolute Contraindications Circulatory disease -ischemic heart disease -cerebrovasular accidents -significant hypertension -arterial or venous thrombosis -any acquired or inherited prothrombotic tendency -any significant risk factors for cardiovascular disease Acute or severe liver disease Estrogen dependant neoplasm, particularly breast cancer Focal migraneRelative Contraindications Generalized migrane Long term immobilization Irregular undiagnosed vaginal bleeding Less severe risk of cardiovascular diseases e.g. obesity, heavy

smoking, diabetes. 

Side effects

Minor side effects:CNS: headache, depression, loss of libidoGIT: nausea, vomiting, weight gain,

bloatedness, gallstones, cholestatic jaundice Genitourinary: irregular bleeding, vaginal

discharge (ectropion)Growth of fibroidsBreast: mastalgia, increased risk of breast

cancer.Miscellaneous: chloasma, leg cramps

Serious side effects:Venous thromboembolism:the higher dose estrogen in

the pills the higher prothrombotic tendency,3rd generation progestogens have twice the risk of thrumboembolism(TE) than 2nd generation progestogens.

Risk of VTE5/100000 general population15/100000 2nd generation COC30/100000 3rd generation COC60/100000 pregnancyArterial disease: Cerebrovascular accident (CVA), Myocardial infarction

(MI) have extremely small increased risk of occurrence, however smoker women more than 35 years old have increased risk for such complications. Around 1% of women taking COC will become significantly hypertensive and should be advised to stop pills.

Breast cancer:Data shows small increase in risk of developing breast

ca among current COC users, this is more significant for women in their 40s as the background risk for breast cancer is higher.

Beyond 10 years of stopping the pills there was no increased risk of breast cancer for younger user.

Cervical cancer:Barrier methods confer some protection and any

association identified in epidemiological studies may be simply the result of inadequate adjustment for sexual behavior. Women with persistent infection with HPV using hormonal contraception for more than 5 years had increased relative risk of cervical cancer of 2.8.

Recent evidence has suggested an increased risk of adenocarcinoma among long term users but this is a rare tumor.

Liver cancer:Benign hepatic adenoma is a rare consequence of

COC useOvarian, endometrial and colon cancer:COCP protects against ovarian cancer with 50%

reduced risk of epithelial type after 5 year of use the protective effect last for at least 10 years after pill use stops. The effect may be related to the reduction of total number of ovulation and therefore rupture of ovarian capsule. And COCP reduces the risk of endometrial cancer the effect is strongly related to duration of use and is sustained for perhaps as long as 15 years after stopping the pills. There is some evidence to suggest that COC may confer protection against colon cancer.

How late are you? Less than 12 hr don't worry. Just take delayed pill at

onceand further

pills as usual

    more than 12 hr take the Most recently delayednow, discard any earlier pillsuse extra precautionsfor the next 7 days 

  how many pills are left in the pack after the most recently delayed pill ,<7 pills >7 pills When you have finished The pack, leave the usual 7D break When you have finished the pack, before starting next pack start the next pack next day without a break

  combined hormonal patches

Transdermal patch containing estrogen and progestogen, are applied weekly for 3 wk after which there is a patch –free wk. contraceptive patches have the same risks/benefits as COC, although they are more expensive, may have better compliance. limited data suggests that the overall average estrogen concentration is higher, Therefore, these patients should be made aware of the possible increased risk of thromboembolism, specifically DVT and PE in combined hormonal patches users. There does not appear to be an increased risk of heart attack and stroke in these patients.

Vaginal Estrogen and Progestin Hormonal Contraception-(NuvaRing):

The ring is placed in the vagina for 3 weeks (it is

likely effective for 4 weeks), and is removed for 1 week to allow for a withdrawal bleed. Again, this hormone-free period can be

skipped to allow for continuous dosing, typically for 3 months.

 Progestogen –only contraception(PO-CONTRACEPTION)

Progesterone-only contraception consists of oral, injectable, implantable, and intrauterine options (the Mirena IUS)

These all function primarily using the same mechanisms: thickening the cervical mucus, inhibiting sperm motility, and thinning the endometrial lining so that it is not suitable for implantation.higher dose progesterone-only methods will also act centrally and inhibit ovulation.

The common side effects of PO methods include:

Erratic or absent menstrual bleeding.Functional ovarian cyst(persistent follicle) Breast tendernessAcneSexually transmitted infection hormonal

contraception may be associated with an increased risk of Chlamydia and gonorrhea, especially with depoprovera which causes hypoestrogenism, thinning of vaginal epithelium may increase the risk of infection.

Relative contraindications for use of POC:

  Breast feeding at least 6 wk postpartum Current DVT, PE Previous breast cancer with no evidence of disease for 5 yr Active viral hepatitis Benign hepatic adenoma Severe decompensated cirrhosis Malignant hepatoma Current or history of ischemic heart disease , stroke Migraine with aura Unexplained vaginal bleeding Multiple risk factors for arterial cardiovascular disease BP>160/100 mmHg Vascular disease Diabetes with nephropathy

Progestin-Only Oral Contraception Pills (The Minipill):

Suits women who cannot take the COC, but have relatively higher failure rate, ideal for women at times of lower fertility, if fail make those women at higher risk of ectopic pregnancy. Older preparation contain 2nd generation at low dose, the newer ones contain 3rd generation progestogen at higher dose to inhibit ovulation. The POP is taken every day without a break

Particular indication for POP include:Breast feedingOlder ageCardiovascular riskDiabetes

Injectables progestogens:

Depot medroxyprogesteron acetate( depoprovera) 150 mg injection last for12-13 wk

Norethisterone enanthate 200mg only last for 8wkDepoprovera is highly effective method of contraceptionMost women develop very light or absent menstruationIt improves PMS other menstrual problems like painful or

heavy periods.Particularly suits patients with poor complianceParticular side effectsWeight gain 3 Kg in the 1st year.Delay in regaining fertility( 6mo.-1yr)Persistent menstrual irregularitiesWith very long term use increases osteoporosis

The Effects of Depo-Provera Use on Bone Mineralization

Bone density is decreased in women using Depo-ProveraThe decrease in bone density is most rapid in the first year

of useThe decrease in bone density increases with length of useThe decrease in bone density is reversible and occurs over

6 mo to 2 yearsThere is no role for the use of bone density screening

(DEXA) in DMPA usersThere is no role for the use of bisphosphonates, estrogens,

SERMS in DMPA usersWomen on Depo-Provera should be encouraged to take

calcium and vitamin D, tostop smoking, and to do regular weight-bearing ex

Subdermal implant:

Implanon consist of single silastic rod that is inserted locally under local anesthesia in to upper arm it superseded the 6 rod implant norplant. It's highly effective and there have been no genuine failures reported with it.

It lasts for 3 years, particularly benefit poor compliant women who need reliable long term contraception, with rapid regaining of fertility.

Patient management:

Careful teaching and explanation of the method, detailed past medical and family history, examine the BP, body weight. Doing pelvic and breast exam are not necessary. Start with 30 mcg EE, 2nd generation progestogens as these are safest and cheapest; explain what to do if they miss taking their pills

How late are you? Less than 12 hr don't worry. Just take delayed pill at

onceand further

pills as usual

    more than 12 hr take the Most recently delayednow, discard any earlier pillsuse extra precautionsfor the next 7 days 

  how many pills are left in the pack after the most recently delayed pill ,<7 pills >7 pills When you have finished The pack, leave the usual 7D break When you have finished the pack, before starting next pack start the next pack next day without a break