CONTRACEPTIONCONTRACEPTION

FEMALE CONTRACEPTIONFEMALE CONTRACEPTION

Barrier MethodsBarrier Methods DiaphragmDiaphragm Cervical capCervical cap Female condomFemale condomHormonal Methods Hormonal Methods Oral contraceptive - Combined oestrogen/Oral contraceptive - Combined oestrogen/ progestogenprogestogen - Progestogen only- Progestogen only Depot progestogens Depot progestogens –– Injections Injections - Subcutaneous silicone- Subcutaneous silicone implantsimplants Vaginal - Silicone rings releasing oestrogen & Vaginal - Silicone rings releasing oestrogen &

progestogenprogestogen

FEMALE CONTRACEPTIONFEMALE CONTRACEPTION

Intra Uterine Devices Intra Uterine Devices InertInert Copper bearingCopper bearing Progestogen releasing.Progestogen releasing.

Natural Methods Natural Methods Rhythm Rhythm Breast feeding (while baby is totally breast fed)Breast feeding (while baby is totally breast fed)

Spermicides Spermicides Creams, Films, Foams, Jellies, Pessaries, SpongesCreams, Films, Foams, Jellies, Pessaries, Sponges (All of these are mainly Nonoxynol based.)(All of these are mainly Nonoxynol based.)

FEMALE CONTRACEPTIONFEMALE CONTRACEPTION

Surgical Methods Surgical Methods Laparoscopic sterilisation - RingsLaparoscopic sterilisation - Rings

- Clips- Clips

- Bipolar diathermy- Bipolar diathermy

- Laser- Laser Tubal ligationTubal ligation

Immunological MethodsImmunological Methods

- These are still at an investigative stage.- These are still at an investigative stage.

MALE CONTRACEPTIONMALE CONTRACEPTION

CondomCondom VasectomyVasectomy Male oral contraception with androgensMale oral contraception with androgens

and with cotton seed oiland with cotton seed oil Immunological contraception Immunological contraception

Still at Still at investigative investigative stagestage..

Relative popularity of methods

(National Opinion Poll, 1990, Schering Healthcare. (National Opinion Poll, 1990, Schering Healthcare. Women aged 16-44.) Women aged 16-44.)

Oral contraception 32%Oral contraception 32% No contraception 22%No contraception 22% Condoms 17% Condoms 17% Female sterilisation 12%Female sterilisation 12% Male sterilisation 12%Male sterilisation 12% IUCD 8%IUCD 8% Diaphragm/Cap 2%Diaphragm/Cap 2% Withdrawal 2%Withdrawal 2% Rhythm 0.5%Rhythm 0.5%

EFFECTIVENESS OF FAMILY PLANNINGEFFECTIVENESS OF FAMILY PLANNING

METHODMETHODAs commonly usedAs commonly usedUsed correctly & Used correctly & consistentlyconsistently

VasectomyVasectomy0.20.20.10.1

DMPADMPA0.30.30.30.3

♀♀SterilizationSterilization0.50.50.50.5

Cu IUCDCu IUCD0.80.80.60.6

Progestrone OCP Progestrone OCP /Breast feeding/Breast feeding

110.50.5

Lactational Lactational amenorrheaamenorrhea

220.50.5

Combined OCPCombined OCP6-86-80.10.1

Progestrone OCP Progestrone OCP /Not breast feeding/Not breast feeding

8-98-90.50.5

♂ ♂ CondomCondom141433

Coitus interruptusCoitus interruptus191944

Pregnancies /100 women /1st year of use

EFFECTIVENESS OF FAMILY PLANNINGEFFECTIVENESS OF FAMILY PLANNING

Diaphram with Diaphram with spermicidespermicide

202066

Fertility awareness Fertility awareness based methodbased method

20201-91-9

♀ ♀ CondomCondom212155

SpermicidesSpermicides262666

Cervical capCervical cap

Nulliparous womenNulliparous women202099

Cervical capCervical cap

Parous womenParous women40402626

No methodNo method85858585

PROGESTIN ONLY HORMONAL PROGESTIN ONLY HORMONAL CONTRACEPTIONCONTRACEPTION

INJECTABLE PROGESTININJECTABLE PROGESTIN

DEPOT MEDROXYPROGESTRONE ACETATEDEPOT MEDROXYPROGESTRONE ACETATE

Introduced in 1967 & used by millions of women Introduced in 1967 & used by millions of women worldwideworldwide

Highly effective with a failure rate Highly effective with a failure rate < 0.3% / year< 0.3% / year

Mechanism of actionMechanism of action Inhibiting the secretion of pituitary gonadotropins Inhibiting the secretion of pituitary gonadotropins

suppression of ovulationsuppression of ovulation 1ry mechanism1ry mechanism ↑↑ ↑↑ viscosity of Cx mucousviscosity of Cx mucous Induces endometrial atrophyInduces endometrial atrophy

DMPA INDICATIONSDMPA INDICATIONS

Any women seeking reliable, reversible, coitally Any women seeking reliable, reversible, coitally independent method of contraception in the independent method of contraception in the absence of contraindicationsabsence of contraindications

Women who have difficulty complying with other Women who have difficulty complying with other methods / it does not require daily attentionmethods / it does not require daily attention

Women with contraindication to estrogensWomen with contraindication to estrogens Women >35 Y who smokeWomen >35 Y who smoke Women with migraine headacheWomen with migraine headache Women who are breastfeedingWomen who are breastfeeding Women with endometriosisWomen with endometriosis Women with sickle cell diseaseWomen with sickle cell disease Women taking anticonvulsant medicationsWomen taking anticonvulsant medications Mentally handicapped womenMentally handicapped women

DMPA CONTRAINDICATIONSDMPA CONTRAINDICATIONS

Absolute contraindicationsAbsolute contraindications PregnancyPregnancy Unexplained vaginal bleedingUnexplained vaginal bleeding Current breast caCurrent breast ca

Relative contraindicationsRelative contraindications Severe liver cirrhosisSevere liver cirrhosis Active viral hepatitisActive viral hepatitis Benign hepatic adenomaBenign hepatic adenoma

DMPA NON-CONTRACEPTIVE BENIFITSDMPA NON-CONTRACEPTIVE BENIFITS

Amennorrhea Amennorrhea (55-60% at 12 M / 68% at 24 M )(55-60% at 12 M / 68% at 24 M ) with subsequent reduction in dysmenorrhea & with subsequent reduction in dysmenorrhea & anemiaanemia

↓↓ ↓↓ risk of endometrial carisk of endometrial ca ↓↓ ↓↓ symptoms associated with endometriosis, PMS, & symptoms associated with endometriosis, PMS, &

chronic pelvic painchronic pelvic pain ↓↓ ↓↓ incidence of seizuresincidence of seizures Possible ↓↓ risk of PIDPossible ↓↓ risk of PID Possible ↓↓ incidence of sickle cell crisis Possible ↓↓ incidence of sickle cell crisis

DMPA SIDE-EFFECTSDMPA SIDE-EFFECTS

1- Menstrual cycle disturbance1- Menstrual cycle disturbance Irregular bleeding Irregular bleeding ↓ in frequency & amount over ↓ in frequency & amount over

timetime Abnormally heavy or prolonged occurred only in 1-2%Abnormally heavy or prolonged occurred only in 1-2% Amennorrhea 55-60% at 12 MAmennorrhea 55-60% at 12 M

68% at 24 M68% at 24 M

2-Hormonal side effects2-Hormonal side effects Headache 17%Headache 17% AcneAcne ↓↓ ↓↓ libidolibido NauseaNausea Breast tendernessBreast tenderness

DMPA SIDE-EFFECTSDMPA SIDE-EFFECTS

3-Weight gain3-Weight gain 56% 56% ↑↑ Wt ( mean gain 4.1 kg) ↑↑ Wt ( mean gain 4.1 kg) possibly through possibly through

appetite stimulation & a mild anabolic effectappetite stimulation & a mild anabolic effect

- 2.5 kg in 1- 2.5 kg in 1stst Y Y

-3.7 kg in 2 Y-3.7 kg in 2 Y

-6.3 kg in 4 Y-6.3 kg in 4 Y 44% ↓ Wt or maintained (mean loss 1.7 kg)44% ↓ Wt or maintained (mean loss 1.7 kg)

4-Mood effects4-Mood effects Prospective studies did not demonstrate ↑ depressive Prospective studies did not demonstrate ↑ depressive

symptomssymptoms Some women discontinue use because of mood Some women discontinue use because of mood

changeschanges

DMPA RISKSDMPA RISKS

1-Delayed return of fertility1-Delayed return of fertility An average of 9 months delay before restoration of An average of 9 months delay before restoration of

full fertility after last injectionfull fertility after last injection Rate of conception 50% at 10 M, 90% at 24 MRate of conception 50% at 10 M, 90% at 24 M

2-Reduction in bone mineral density2-Reduction in bone mineral density A mean loss of BMD at the lumbar spine 0.87-3.5%A mean loss of BMD at the lumbar spine 0.87-3.5% Does not induce osteoporosisDoes not induce osteoporosis It improves after discontinuation of use It improves after discontinuation of use Comparison of past users to controls did not Comparison of past users to controls did not

demonstrate any deference demonstrate any deference

3-VTE, CVD, Stroke 3-VTE, CVD, Stroke No No ↑ risk↑ risk

DMPA DOSAGE & ADMINISTERATIONDMPA DOSAGE & ADMINISTERATION

150 mg IM every 12 Wks150 mg IM every 12 Wks

Started during the 1Started during the 1stst 5 days of menses or within 5 days of menses or within 5 days of stopping COCP5 days of stopping COCP

Effective within 24 hrs of injection if given during Effective within 24 hrs of injection if given during the 1the 1stst 5 days of the cycles 5 days of the cycles

If given later than D5 of the cycle If given later than D5 of the cycle back up back up method of contraception must be used for 1 wkmethod of contraception must be used for 1 wk

DMPA TROUBLESHOOTINGDMPA TROUBLESHOOTING

1- Menstrual cycle disturbance1- Menstrual cycle disturbance If irregular bleeding persists after the 1If irregular bleeding persists after the 1stst 6 M of 6 M of

use use rule out other causes of abnormal bleeding rule out other causes of abnormal bleedingManagement optionsManagement options ↑↑ ↑↑ DMPA dosage DMPA dosage 225-300 mg for 2-3 injections 225-300 mg for 2-3 injections ↓↓ ↓↓ interval between dosageinterval between dosage Supplemental estrogen therapy :Supplemental estrogen therapy : 0.625 conjugated equine estrogen po 0.625 conjugated equine estrogen po ––28 days28 days 1-2 mg 17ß-estradiole po –28 days1-2 mg 17ß-estradiole po –28 daysTransdermal estrogen 50-100 Transdermal estrogen 50-100 μμg 17ß-estradiole g 17ß-estradiole

patch for 25 dayspatch for 25 days Nonsteroidal anti-inflammatory Nonsteroidal anti-inflammatory ibuprofen 400- ibuprofen 400-

800 mg bd for 10 days800 mg bd for 10 days Adding COCP for 1-3 MAdding COCP for 1-3 M

DMPA TROUBLESHOOTINGDMPA TROUBLESHOOTING

2-Late injection2-Late injection <<14 wks since last injection it can be given14 wks since last injection it can be given ≥ ≥ 14 wks since last injection14 wks since last injection -ve serum ß hcg, no intercourse for last 10 days-ve serum ß hcg, no intercourse for last 10 days give the injectiongive the injection back up contraception must be used for 2 wksback up contraception must be used for 2 wks ≥ ≥ 14 wks since last injection14 wks since last injection -ve serum ß hcg,intercourse within the last 10 D-ve serum ß hcg,intercourse within the last 10 D give the injectiongive the injection back up contraception must be used for 2 wksback up contraception must be used for 2 wksRepeat serum ß hcg –2 wksRepeat serum ß hcg –2 wksNot teratogenic if inadvertently given during Not teratogenic if inadvertently given during

pregnancypregnancy