Dr. Badar Uddin Umar 1

 The objective of the lecture is to discuss the-  Definition of contraception  Name different contraceptive methods with advantages and disadvantages  Know composition of different hormonal contraceptives  Describe mechanism of action of hormonal contraceptives  Advantages and disadvantages of oral contraceptives  Describe other contraceptive methods Lecture Objectives 43 2

 At the end of the lecture, students should be able to List the contraceptive methods 43.2 Explain the advantages and disadvantages of contraceptive methods 43.3 Classify hormonal contraceptives 43.4 Describe the composition of combination oral contraceptives 43.5 Describe the mechanism of action of hormonal contraceptives 43.6 List the advantages and disadvantages of oral contraceptives 43.7 Recognize other contraceptive methods (emergency contraception, post coital contraception, injectable contraceptive, implantable contraceptive) Learning Objectives 43 3

  Contraception means prevention of physical reproduction  There are several methods of contraception-  Hormonal contraceptives  Non-hormonal methods:  Barrier method  IUD  Methods based on information  Permanent sterilization Contraception 4

 Comparison of contraceptive use among United States women ages 15 to 44 years 5

 Three general strategies are adopted:  Prevent ovulation  Prevent fertilization  Keep sperm & oocyte away from each other  Prevent implantation Strategies of Contraception….. 6

 Comparison of failure rate for various methods of contraception 7

  Hormonal contraceptives are -  Oral pills  Implants  Injectables Hormonal Contraception 8

 1)Combined oral pills:  Combinations of estrogen & progestins 2)Progesterone only pill:  Continuous progestins therapy without concomitant administration of oestrogens 3) Estrogen containing preparations: e.g.  postcoital pill Oral contraceptives… 9

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  The oestrogen in most combined preparations is ethinylestradiol  A few preparations contain mestranol instead  The progestogen may be norethisterone, levonorgestrel, ethynodiol, or  In 'third-generation' pills-desogestrel or gestodene  more potent, have less androgenic action and cause less change in lipoprotein metabolism but  which probably cause a greater risk of thromboembolism Contents of oral pills 11

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  The combined pills are started on the 1 st day of the cycle ( menstruation)  21 tablets for 21 days followed by no pill for next 7 days  This 7 days for menstrual bleeding which is anovular How to take oral pills…. 13

  Hormonal contraceptives must be extremely safe & highly effective  Onset of action must be quick & completely reversible  Alternative methods are less reliable & inconvenient Principles for hormonal contraceptives 14

 Hypothalamus ↓ GnRH (- antagonist) (+ agonist) Pituitary ↓ (LH,FSH) Ovary/ testis ↓ Estrogens, Progesterone/Testosterone Mechanism of action of hormonal contraceptives 15

  Combined estrogen - progestogen oral contraceptives have been extensively used  The principal mechanism is:  Inhibition of ovulation through inhibition of gonadotrophin secretion from hypothalamus & pituitary Mechanism of action… 16

  Prevention of fertilization: F emale genital tract becomes inhospitable because combination preparation alters-  cervical mucosa,  fallopian tubes’ motility & secretion  the uterine endometrium Mechanism of action… 17

  Inhibition of implantation:  Implantation does not occur until the endometrium is in right state  Delicate balance between estrogen & progestins maintain the endometrium, this can be disturbed easily Mechanism of action… 18

  Estrogen alone is not completely reliable moreover, at the necessary dose, there are chance of thromboembolism & endometrial cancer  Progesterones, used alone inhibit ovulation up to 40% cycle Hormonal contraceptives… 19

  Progesterone renders cervical mucosa less easily penetrable by sperm  Cervical mucosa becomes more viscous  It induces a premature secretory changes in endometrium so that implantation does not occur Hormonal contraceptives… 20

 Progesterones can cause:  Break-through bleeding  Raised blood pressure  Arterial diseases & blood lipid profile are adversely affected Hormonal contraceptives… 21

  An appropriate dose of combined pill (estrogen + progesterone) gives excellent reliability with good menstrual cycle control  Combination of both hormone reduces dose & adverse effects of each Hormonal contraceptives… 22

 Some rules-  The pill should be taken at same time, every day  Withdrawal bleeding assures that she is not pregnant  If one pill is missed, when remembered, must be taken within 12 hrs.  If more than 2-3 days gap, barrier method should be used for 7 days Hormonal contraceptives 23

  The next cycle (packet) should be taken without a gap e.g. postponing the following menstruation  Missed pill may initiate the process of ovulation & that is why these must be followed Hormonal contraceptives…Some rules- 24

  Intercurrent gut upset, vomiting or diarrhea within 3 hours of taking pill should be treated as missed pill  Enzyme inducers: phenytoin, rifampicin etc. and broad spectrum antibiotics such as doxycycline, ampicillin which alter gut flora Missed pill 25

  The combination agents are divided into-  Monophasic  Biphasic &  Triphasic forms  The preparations for oral use are well absorbed, distributed, metabolized, eliminated & they are not altered by each other Hormonal contraceptives 26

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Combined pills Monophasic combinationOestrogenmgProgestinsmg Nordette (1-21)Ethinyl estradiol0.03L-Norgestrel0.15 Alesse (1-21)Ethinyl estradiol0.02L-Norgestrel0.1 Ovcon (1-21)Ethinyl estradiol0.035Norethindrone0.4 Norinyl (1-21)Mestranol0.05Norethindrone1 Biphasic combination Days 1-10Ethinyl estradiol0.035Norethindrone0.5 Days 11-21Ethinyl estradiol0.035Norethindrone1 Triphasic combination Days 1-6Ethinyl estradiol0.03L-Norgestrel0.05 Days 7-11Ethinyl estradiol0.04L-Norgestrel0.075 Days 12-21Ethinyl estradiol0.03L-Norgestrel

Progesterone only preparation Daily progestin Micronor Norethindrone0.35 mg OvretteD,L Norgestrel0.075 mg Implantable progestin preparation L- Norgestrel6 tubes of 36 mg of each 29

  Depot medroxyprogesterone acetate (DMPA), 150 mg injectable contraceptive for 3 month (90 days)  Suppression of ovulation occurs for 14 weeks & there is amenorrhea  Breakthrough bleeding is common  Ovulation suppression sometimes persists Progesterone only preparation 30

Postcoital contraceptives Conjugated estrogens 10 mgTDS for 5 days Ethinyl estradiol2.5 mgBD for 5 days Diethyl stilbesterol 50 mgDaily for 5 days Mifepristone+ Misoprostol 600 mg+400 μg Mifepristone on day 1 Misoprostol on day 3 L- Norgestrel0.75 mgBD for 1day Norgestrel+ Ethinyl estradiol 0.5 mg+0.05 mg2 tabs stat then 2 tabs after 12 hour 31

 Clinical uses of contraceptives:  Most common uses are for contraception  For treatment of endometriosis  Severe dysmenorrhoea (suppression of ovulation) leads to painless menstruation  Dysfunctional uterine bleeding Hormonal Contraceptives 32

  The oral (estrogen + progesterone) combination preparation gives % effectiveness  Missed pills, antiepileptics (not sodium valproate), broad spectrum antibiotics may lead to failure Hormonal Contraceptives 33

 Advantages of oral contraceptives- Benefits in addition to contraception:  Estrogen- progesterone combination pill reduces risk of :  Ovarian cyst & cancer  Endometrial cancer  Ectopic pregnancy  Anaemia  Benign breast disease  Uterine fibroid  Menorrhagea  Irregular menstruation  Premenstrual tension &  Dysmenorrhoea 34

 Absolute contraindications:  History of venous, arterial thromboembolism or any cardiac disease  Any estrogen or progesterone dependant neoplasia  Transient ischemic attack  Infective hepatitis (until 3 months after liver function tests have become normal) Disadvantages of oral contraceptives- Contraindications of hormonal contraceptives: 35

  Cholestatic jaundice  Migraine headache  Carcinoma of breast or genital tract  Undiagnosed vaginal bleeding, systemic lupus erythromatosus, hydatidiform mole Disadvantages of oral contraceptives- Contraindications of hormonal contraceptives: 36

  Family history of venous thromboembolism, arterial disease or any prothombotic condition  Diabetes mellitus which may be precipitated  Hypertension (>160/100 mm of Hg)  Smoking, >40 sticks a day  Age >35  Obesity (BMI >39 kg/m 2 )  Long term immobility  Breast- feeding mother Disadvantages of oral contraceptives- Relative contraindications 37

  Oral contraceptives should not be used during perimenopausal period  Menopause cannot be detected due to withdrawal bleeding  Annually blood pressure, blood glucose level, serum lipid profile & if possible LH/FSH level should be measured Cautions…. 38

 Some preexisting disorders like-  Asthma  Liver disease  Optic neuritis or  Convulsive disorders Should not be prescribed in- 39 May precipitate with hormonal contraceptives So should not be prescribed

  Congestive cardiac failure patient should not receive hormonal contraceptives as they can produce edema which will aggravate the disease  Fibroid uterus should avoid estrogen containing preparation, progesterone only pills will be useful Hormonal contraceptions 40

  Adolescents must avoid hormonal contraceptives because their epiphyseal closure yet not been completed  Psychosis is also aggravated with steroids Hormonal contraceptions 41

  Continuous use of combined pill suppress ovarian function  After discontinuance of pill, 75% will ovulate in the 1 st post treatment month  97% will ovulate in the 3 rd month  2% remain amenorrhic Hormonal contraceptions 42

 Mild adverse effects:  Nausea  Mastalgia  Breakthrough bleeding  Edema  Headache  Failure to withdrawal bleeding, confusion with pregnancy Adverse effects of hormonal contraceptives 43

 Breakthrough bleeding/spotting :  Is the commonest problem with progesterone only preparation  This can be minimized by biphasic or triphasic combination pills Moderate adverse effects: 44

  Weight gain - androgen like progestins are more responsible so shifting to estrogen preparations or dieting is the solution  Increased skin pigmentation  Acne & hirsutism also precipitate with androgen like progestins Moderate adverse effects: 45

  Bacteriurea & vaginal infection are more common & difficult to treat the patient taking hormonal contraceptives  Amenorrhea occur for several years in some recipient after cessation of hormonal contraceptives Moderate adverse effects: 46

  Vascular disorders:  Venous thromboembolic disease (3 times higher in hormonal estrogen) contraceptive recipients  Myocardial infarction  Cerebrovascular diseases Severe adverse effects 47

  Gastrointestinal disorders:  cholestatic jaundice, cholangitis, cholecystits, hepatic adenoma, ischaemic bowel disease  Depression  Cancer-cervical cancer  Alopecia  Erythema multiforme  Erythema nodosum Severe adverse effects 48

Other methods…. 49

  Birth control shot given once every three months to prevent pregnancy  99.7% effective preventing pregnancy  No daily pills to remember  Mechanism of action:  Stops ovulation  Stops menstrual cycles!!  Thickens cervical mucus Injectable Contraceptives- Depo-Provera

  Extremely irregular menstrual bleeding and spotting for 3-6 months!  NO PERIOD after 3-6 months  Weight change  Breast tenderness  Mood change *NOT EVERY WOMAN HAS SIDE-EFFECTS! Side effects

  Implants are placed in the body filled with hormone that prevents pregnancy  Physically inserted in simple 15 minute outpatient procedure  Plastic capsules the size of paper matchsticks inserted under the skin in the arm  99.95% effectiveness rate Implants

 Norplant I vs. Norplant II  Six capsules  Five years  Two capsules  Three years

 Norplant… Implant

  Should be considered long term birth control  Requires no upkeep  Extremely effective in pregnancy prevention > 99% Norplant Considerations

  Must be taken within 72 hours of the act of unprotected intercourse or failure of contraception method Emergency Contraception (ECP)

  Spermicides  Male Condom  Female Condom  Diaphragm  Cervical Cap Barrier methods

  Prevents pregnancy blocks the egg and sperm from meeting  Barrier methods have higher failure rates than hormonal methods due to design and human error Barrier methods…

  Chemicals kill sperm in the vagina  Different forms: - Jelly-Film -Foam - Suppository  Some work instantly, others require pre- insertion  Only 76% effective (used alone), should be used in combination with another method i.e., condoms Spermicides

  Most common and effective barrier method when used properly  Latex and Polyurethane should only be used in the prevention of pregnancy and spread of STD’s (including HIV) Male condom

  Made as an alternative to male condoms  Polyurethane  Physically inserted in the vagina  Perfect rate = 95%  Typical rate = 79%  Woman can use female condom if partner refuses Female condom

  Perfect Effectiveness Rate = 94%  Typical Effectiveness Rate = 80%  Latex barrier placed inside vagina during intercourse  Fitted by physician  Spermicidal jelly before insertion  Inserted up to 18 hours before intercourse and can be left in for a total of 24 hours Diaphragm

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  Latex barrier inserted in vagina before intercourse  “Caps” around cervix with suction  Fill with spermicidal jelly prior to use  Can be left in body for up to a total of 48 hours  Must be left in place six hours after sexual intercourse  Perfect effectiveness rate = 91% Cervical cap

  T-shaped object placed in the uterus to prevent pregnancy  Must be on period during insertion  A Natural childbirth required to use IUD  Extremely effective without using hormones > 97 %  Must be in monogamous relationship Intrauterine devices (IUDs)

  Procedure performed on a man or a woman permanently sterilizes  Female = Tubal Ligation  Male = Vasectomy Sterilization

  Surgical procedure performed on a woman  Fallopian tubes are cut, tied, cauterized, prevents eggs from reaching sperm  Failure rates vary by procedure, from 0.8%- 3.7%  May experience heavier periods Tubal ligation

  Male sterilization procedure  Ligation of Vas Deferens tube  No-scalpel technique available  Faster and easier recovery than a tubal ligation  Failure rate = 0.1%, more effective than female sterilization Vasectomy

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  Withdrawal  Natural Family Planning  Fertility Awareness Method  Abstinence Methods based on information

  Removal of penis from the vagina before ejaculation occurs  NOT a sufficient method of birth control by itself  Effectiveness rate is 80% (very unpredictable in teens, wide variation)  1 of 5 women practicing withdrawal become pregnant  Very difficult for a male to ‘control’ Withdrawal

  Women take a class on the menstrual cycle to calculate more fertile times  Requires special equipment and cannot be self- taught  NFP abstains from sex during the calculated fertile time  FAM uses barrier methods during fertile time  Perfect effectiveness rate = 91%  Typical effectiveness rate = 75%  No 100% safe day-irregular periods Natural Family Planning & Fertility Awareness Method

  Only 100% method of birth control  Abstinence is when partners do not engage in sexual intercourse  Communication between partners is important for those practicing abstinence to be successful Abstinence

  Moral or religious values  Personal beliefs  Medical reasons  Not feeling ready for an emotional, intimate relationship  Future plans Reasons for abstaining

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