FERTILITY CONTROL

Men and women have used contraception, in one form or another, for thousands of years. There is no one method that will suit everyone, and individuals will use different types of contraception at different stages in their lives

The characteristics of the ideal contraceptive method are: highly effective no side effects cheap rapidly reversible widespread availability acceptable to all cultures and religions easily distributed can be administrated by non- health care personnel

Virtually all methods of contraception occasionally fail and some are much more effective than others. Failure rates are traditionally expressed as the number of failures per 100 woman-years (HwY ), i.e. the number of pregnancies if 100 women were to use the method for 1 year. Failure rates for some methods vary considerably, largely because of the potential for failure caused by imperfect use (user failure) rather than an intrinsic

Classification Methods not requiring medical cosultation: 1-coitus interruptus 2-safe period[Natural family planning] 3-vaginal spermicides 4-barrier methods include : Male condom Female barriers

Methods requring medical supervision 1-Hormonal contraception: Combined oral contraceptive methods Progesterone-only preparations :include A-progesterone only pills B-injectables C-Subdermal implants D-Hormone-releasing intauterine system

2-Intauterine device 3-Post-coital emergency contraception 4-occlusive diaphragms&caps Perminant methods[sterilization] Female tubal occlusion Male vasectomy

Failre rate for contraception Contraceptive method Combined oral contraceptivepill Progestogen -only pill Depo-Provera Implanon Copper-bearing IUD Levonorgestrel-releasing IUD Male condom Female diaphragm Persona Natural family planning Vasectomy Female sterilization Failure rate /100 women year o

Hormonal contraception

Combined oral contraceptive pills Combined oral contraception (COC) - 'the pill' - was first licensed in the UK in It contains a combination of two hormones: a synthetic oestrogen and a progestogen (a synthetic derivative of progesterone). Since COC was first introduced, the doses of both oestrogen and progestogen have been reduced dramatically, which has considerably improved its safety profile.. Combined oral contraception is easy to use and offers a very high degree of protection against pregnancy, with many other beneficial effects. It is mainly used by young, healthy women.

Combined oral contraceptive pill preparations

Formulations Combined oral contraceptive pills contains both: 1-Synthetic Estrogen (Ethinyl estradiol mostly): The dose of oestrogen varies from 50 to 15 μg (microgram). 2-Synthetic progestogens Either one of these : *First generation(e.g. norethindrone). *Second generation progestins (e.g. levonorgestrel). *Third generation series including gestodene, desogestrel and norgestimate.

Monophasic pills contain standard daily dosages of oestrogen and progestogen. Biphasic or triphasic preparations have two or three incremental variations in hormone dose. Current thinking is that biphasic and triphasic preparations are more complicated for women to use and have few real advantages. Most brands contain 21 pills; one pill to be taken daily, followed by a 7-day pill-free interval. There are also some every-day (ED) preparations that include seven placebo pills that are taken instead of having a pill-free interval. For maximum effectiveness, COC should always be taken regularly at roughly the same time each day.

preparation 1. low-dose pills containing 30μg of ethinyl estradiol 2.high-dose pills contain contain 50 μg estrogen. Higher dosages of oestrogen are strongly linked to increased risks ofboth arterial and venous thrombosis 3.Yasmin contains ethinyl estradiol and drospirenone. Drospirenone has antimineralocorticoid activity. It can help prevent bloating, weight gain, and hypertension, but it can increase serum potassium. Yasmin is contraindicated in patients at risk for hyperkalemia and should not be combined with other drugs that can increase potassium

Mode of action Combined oral contraception acts both centrally and peri pherally. centrally Inhibition of ovulation is by far the most important effect. Both oestrogen and progestogen suppress the release of pituitary follicle stimulating hormone (FSH) and luteinizing hormone (LH), which prevents follicular development within the ovary and therefore ovulation. Peripheral effects include - making the endom trium atrophic and hostile to an implanting embryo - altering cervical mucus to prevent sperm ascending into the uterine cavity.

Contraindications Absolute contra indications Circulatory diseases: - iscihaemic heart disease- cerebrovascular accident - significant hypertension - arterial or venous thrombosis - any acquired or inherited pro-thrombotic tendency - any Significant risk factors for cardiovascularpisease Acute or severe liver disease Oestrogen-dependent neoplasms, particularly breast cancer -Breastfeeding <6 weeks post-partum -Smoking ≥15 cigarettes/day and age ≥35 Focal migraine

Relative contra indications Generalized migraine Long-term immobilization Irregular vagli.nal bleedillg (until a diagnosis has been made) Less severe risk factors for cardiovascular disease, e.g. obesity, heavy smoking, diabetes

Side effects major side effects 1-Venous thromboembolism Oestrogens alter blood clotting and coagulation in a way that induces a pro-thrombotic tendency, although the exact mechanism of this is poorly understood. The higher the dose of oestrogen within COc, the greater the risk of venous thromboembolism (VTE). Type of progestogen also affects the risk of VTE, with users of COC containing third-generation progestogens being twice as likely to sustain a VTE..

The risks ofVTE are: 5 per for normal population, 15 per for users of second-generation COC, 30 per for users of third-generation COC, 60 per for pregnant women

2-Arterial disease *1 per cent of women taking coc will become significantly hypertensive and they should be advised to stop taking COC *The risk of myocardial infarction and thrombotic stroke in young, healthy women using low-dose cac is extremely small. *Cigarette smoking will, however, increase the risk, and any woman who smokes must be advised to stop COC at the age of 35 years. Around.

3-Mortality There is increased mortality in women using the pills over women not using it.this is related to age&smoking habits.Death is most often the result of pulmonary embolism,cerebral or coronary thrombosis. Women who are under 35 years,do not smoke or have hypertention or diabetes have no exess mortality In women over 35 years who are on pill the exess mortality rises&rises more in women who smoke or have hypertention

4-Carcinogenic effect Breast cancer Advising women about the association between breast cancer and COC is very difficult. Most data do show a slight increase in the risk of developing breast cancer among current COC users (relative risk around l. 24). This is not of great significance to young women, as the background rate of breast cancer is very low at their age. However, for a woman in her forties, these are more relevant data, as the background rate of breast cancer is higher. The same data also showed that beyond 10 years after stopping coc there was no increase in breast cancer risk for former coc users

Cervical cancer More than five years of pill use may be associated with small increase risk of cervical carcinoma. Liver cancer Benign hepatic adenoma is a rare consequence of COC use.

Minor side effects Central nervous system Gastrointestinal Genitourinary system Breast miscellaneous Depression Headaches Loss of libido Nausea and vomiting Weight gain Bloatedness Gall-stones Cholestatic jaundice Cystitis Irregular bleeding Vaginal discharge Growth of fibroids Breast pain Increased risk of breast cancer Chloasma (facial pigmentation) Leg cramps

How to use pills The patient begins taking the pills on the first day of menstrual cycle then in the next cycles they are administered in fifth day of the cycle and continue for 21 days, each day at the same time, then discontinued for 7 days to allow for withdrawal bleeding that mimics the normal menstrual cycle which occur after 3-5 days from stopping pills

If pills are missed How late are you? Less than 12 hours late Don't worry. Just take the delayed pill at once, and further pills as usual More than 12 hours late Take the most recently delayed pill now Use extra precautions (condom, for instance) for the next 7 days

Drug interaction *This can occur with enzyme-inducing agents such as some anti-epileptic drugs increase activity of hepatic enzyme so reduce efficacy of COC. Higher dose oestrogen coc containing 50 Mg ethinyl oestradiol may need to be prescribed *Some broad-spectrum antibiotics Ampicillin, Amoxicillin, Tetracycline, Neomycin 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

*Steroids,Ascorbic acid (Vitamin C) and acetaminophen may elevate plasma ethinyl estradiol so increse its efficacy

Positive health benefits *COC users generally have light, pain -free, regular bleed and therefore COC can be used to treat heavy or painful periods i.e menorrhagia & dysmenorrhea *It will also improve premenstrual syndrome (PMS) *reduce the risk of pelvic inflammatory disease (PID). *decreased incidence of benign breast lump *decrease number of functional ovarian cyst *less endometriosis *COC offers long-term protection against both ovarian and endometrial cancers. *It can also be used as a treatment for acne.

Combined oestrogen and progesterone vaginal ring It is soft ring that a woman can insert into vagina; and the Women who use Ring leave the ring in place for 3 weeks during a month. During the 4th week, the ring is removed for 7 days. A new ring is used for each cycle.

Combined hormonal patches A contracept ive t ransdermal patch containing oestrogen and progestogen has been developed 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. Cont raceptive patches have the same risks and benefits as COC and, alt hough they are relatively more expensive, may have better compliance.