Contraception د. ياسمين حمزة

1-Methods not requiring medical consultation:   1-Methods not requiring medical consultation: A-Male :-coitus interrupts -condom(sheath) B-Female:-safe period(rhythm method) -vaginal spermicides & tampons 2-Methods requiring medical supervision: 1-systemic contraception(hormonal contraception): a-oral contraceptive pills(combined preparation ,variable dose preparations) b-progesterone only contraception. 2-injectable contraception. 3-implants 4-IUCD 5-occlusive diaphragm &caps 6-emergrgency contraception(postcoital methods). 3-Permanent methods(sterilization): -female: tubal occlusion -male: vasectomy.

Hormonal contraception:   1-Combined contraceptive: 1- Combined oral contraception(OCCP): contain 2 steroids ,estrogen & progesterone. The estrogen component is ethyinyl estradiol in a dose range ( 20-35&50 µg). The progesterone components vary but all are derivative of 19-nortestosterone ,they are divided into 2nd generation(nor-ethisteron ,levonorgesterel) & 3rd generation(desogesterol & gestodene).The 3rd generation has higher affinity for progesterone receptors & lower affinity for androgen receptors , so they have fewer side effects & fewer effect on CHO & lipid metabolism but no reduction on arterial wall disease or MI , the efficacy is over 99%(failure rate 0.1-1)per 100 women per years.

Mechanism of action:   A-centrally : as estrogen inhibits FSH & progesterone inhibits LH surge , so inhibits ovulation. B-Peripherally : due to progesterone effects the cervical mucus become scanty viscous & hostile to sperm(low spinbarkeit) that will inhibit sperm penetration . The endometrium becomes thin & atrophied & unreceptive to implantation, & there is possibly direct effect on sperm migration in the fallopian tube & ovum transport .

Side effects of combined contraception:   1-Venous thromboembolism: 5/100,000 normal population ,15/100,000 in 2nd generation OCCP ,30/100,000 in 3rd generation OCCP ,60/100,000 in pregnant women , & the risk increased by age , obesity acquired or congenital thrombophilia . 2-Arterial disease: in 1% of women taking OCCP will have hypertension, & should advice to stop it. 3- Breast cancer: this is not of great significant to young women , but above 40 years it will increase. 4-Drug interaction: this occur with enzyme-inducing agents as anti-epileptics & some broad spectrum antibiotics. 5-CNS:depression ,headache, loss of libido. 6-GIT: nausea,vomiting,wt. gain ,bloating ,gall stone ,cholestatic jaundice. 7-Genito-urinary tract: cystitis, irregular vaginal bleeding , vaginal discharge ,fibroid growth. 8-Miscellaneous: chloasma(facial pigmentation) ,leg cramps.

Positive health benefits: (light pain free regular bleeding),so used for heavy painful cycle ,also improve PMS,decrease PID ,long term protection against ovarian & endometrial cancer, also to treat acne & hairsutism.

Absolute contraindications:   1-Past or present HX of circulatory disease: -proven past venous , arterial thrombosis. -IHD -Multiple risk factor for A-V disease. -Vascular malformation of the brain. -focal migraine. -TIA -Atherogenic lipid disorder. -Thrombophilia. -past cerebral HH -Significant HT. -Structural heart disease.

2- Diseases of the liver:-active liver disease , liver adenoma or carcinoma , gall stone , acute hepatic porphyria. 3-pregnancy. 4-Undiagnosed genital tract disease. 5-Estrogen dependent neoplasm as breast CA. 6-serios condition affected by sex steroid.

Relative CI: 1-Undiagnosed oligomenorrhea   1-Undiagnosed oligomenorrhea 2-Cigarret smoking over age 35Y. 3-Diabetes. 4-Non-focal migraine(generalized migraine). 5-Sickle cell disease. 6-Obesity if associated with other risk factor as DM,heavy smoking. 7-Long term immobilization. 8- Irregular vaginal bleeding.

2-Combined hormonal patches: contain 20µg ethyniylestradiol & 150µg norgesteol/day, each patch for 1 week, for 3 weeks ,with the 4th patch free or placebo. 3- vaginal ring(Nuvaring):releasing 15µg EE,&120µg norgesterol.

2-Progesterone only contraception: currents methods are progesterone only pills ,injectable,subdermal implants,& hormonal IUD. 1-Oral progesterone preparation(POP): are often called (mini-pills),the older form contain a very low dose of 2nd generation progesterone(norethisterone,norgestrel), the newest POP(Cerazette) contain 3rd generation progesterone(desogestrel), &the pill should be taken at the same time every day without break, failure rate (1-3)per 100 women per years ,it is ideal for women with lower fertility as during lactation.

Mechanism of action:   All progesterone-only methods work by a local effects on CX mucous making it hostile to ascending sperm , & on the endometrium making it thin & atrophic ,there by preventing implantation & sperm transport. Higher dose progesterone- only methods will also acts centrally & inhibits ovulation.

3-Presence of cardiovascular risk factors. 4-Diabetes. Disadvantages:  Advantages(indications): 1-Breast feeding. 2-Older women. 3-Presence of cardiovascular risk factors. 4-Diabetes.   Disadvantages: 1-Menstrual disturbances & amenorrhea. 2-acne. 3-breast tenderness. 4- functional ovarian cyst. 5-loss of libido.

 2-Injectable progesterone: Two injectable progesterone are marketed: 1-Depoprovera(depo-medroxyprogesterone acetate) 150mg every 3 months . 2-Norethisteron enanthate 200 mg every 2months. Both are given by deep IM injection in the gluteal area. MOA: suppression of ovulation ,effect on CX mucous & endometrial effects.Failar rate (0.1-1)per 100 women per year.

Advantages:  1-highly effective. 2-redaction in menstrual blood flow. 3- protection against PID. Disadvantages: 1-Delaye in return to fertility (up to 18 months) 2-Wt. gain & increase appetite. 3-Menstrual disturbance & spotting. 4-Long term use lead to osteoporosis. 5-Progesterone side effects as acne, breast tenderness.

3-Subdermal implants(Implanon): it consist of single rode containing 68mg of 3-ketodesogesterl(metabolites of desogesterel) inserted sub dermally in the upper arm under local anesthetic , provide contraception for 3 years, irregular cycle   4-Intrauterine hormonal contraception(Mirena):it prevents pregnancy by local a local hormone effects on the CX & endometrium. It contain 52mg levonorgesterl releasing 20µg of it/day for 5 years.