FAMILY PLANNING & CONTRACEPTION ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD

FAMILY PLANNING Aspects of the problem national social personal ethnic In no other branch of medicine are social, religious, and political forces more obvious than in family planning.

CONTRACEPTION Definition – avoiding an unwanted pregnancy Elective abortion is not a contraceptive technique. no contraception + presumably fertile sex partners = about 90 % of women will conceive within 1 year. While there is no totally safe contraceptive method, and the lack of contraception is even more dangerous, both are less dangerous than driving an automobile for 1 year.

CONTRACEPTION Classification of the methods the user – male / female the duration – temporary (reversible) / permanent (irreversible) the type: hormonal, mechanical, chemical, natural, surgical, mixed emergency or routine contraception

CONTRACEPTION Effectiveness – Pearl Index Total no. of accidental pregnancies x 1200 / total months of use = % per 100 women-years of exposure Failure rates for some methods vary considerably, largely because of the potential for failure caused by imperfect use (user failure) rather than an intrinsic failure of the method itself.

The characteristics of the ideal contraceptive method CONTRACEPTION The characteristics of the ideal contraceptive method • highly effective • no side effects • cheap / gratis • independent of intercourse • rapidly reversible • widespread availability • acceptable to all cultures and religions • easily distributed • easily administrated (by non - healthcare personnel).

Contraceptive counselling CONTRACEPTION Contraceptive counselling the contraceptive choice the provision of method the advice on using the method

Classification CONTRACEPTION Hormonal contraception Intrauterine contraception Copper intrauterine device (IUD) Hormone-releasing intrauterine system (IUS) Barrier methods Condoms (male, female) Female barriers Natural family planning methods: Periodic abstinence, Coitus interruptus, Lactation Emergency contraception Sterilization Female sterilization Vasectomy

CONTRACEPTION Hormonal contraception Combined oral contraceptive pills (COC) Combined hormonal patches Vaginal ring Progestogen-only preparations - Progestogen-only pills (POP) - Injectables - Subdermal implants

Hormonal contraception Combined hormonal patches – Ortho Evra Vaginal ring - NuvaRing etonogestrel + EE

Hormonal contraception Progestogen-only preparations Progestogen-only pills (POP) – Cerazette contains desogestrel. Injectables - norethindrone enanthate (NET – EN) – 8 weeks - medroxiprogesteron acetate depot (DMPA) – 12 weeks

Hormonal contraception Subdermal implants delivery of a steroid progestin from polymer capsules or rods placed under the skin. Implanon - 4 cm/ 2 mm Implanon rod contains 68 milligrams of etonogestrel which is released over a 3 year period.

COMBINED ORAL CONTRACEPTIVE PILL

Formulations Monophasic (each tablet contains a fixed amount of estrogen and progestin); Biphasic (each tablet contains a fixed amount of estrogen, while the amount of progestin increases in the second half of the cycle); Triphasic (the amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases).

Estrogens Types of estrogen ethinyl estradiol, mestranol, a “prodrug” that is converted in vivo to ethinyl estradiol. estradiol, ex: Zoely - acetat de nomegestrol + estradiol estetrol

Progestins can be classified according to their chemical structure as 19-nortestosteron derivatives: norethisteron, linestrenol, etinodiol diacetat şi levonorgestrel; 17 alfa-hidroxiprogesteron derivatives: medroxiprogesteron acetat, clormadinon acetat, cyproteron acetate; progestines of the new generation: desogestrel, gestodene, dienogest, norgestimate spironoloctone derivatives - drospirenone

EFFICACY The combined OC = a highly effective method of reversible contraception. With perfect use, the combined OC is 99.9% effective in preventing pregnancy. However, typical use = failure rates range from 3 - 8%.

MECHANISM OF ACTION Main mechanism of action is to suppress gonadotropin secretion, thereby inhibiting ovulation.

Additional mechanisms of action MECHANISM OF ACTION Additional mechanisms of action endometrial atrophy, making the endometrium unreceptive to implantation; Increased viscousity of the cervical mucus - impedes sperm transport; effect on fluid secretion and peristalsis within the fallopian tube, which interferes with ovum and sperm transport.

INDICATIONS In the absence of contraindications, use of the combined OC may be considered for any woman seeking a reliable, reversible, coitally-independent method of contraception.

CONTRAINDICATIONS The World Health Organization (WHO) has developed a list of absolute and relative contraindications to the use of combined OCs, based on the available evidence of risks

ABSOLUTE CONTRAINDICATIONS < 6 weeks postpartum if breastfeeding Smoker over the age of 35 (≥ 15 cigarettes per day) Hypertension (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg) Current or past history of venous thromboembolism (VTE) Ischemic heart disease History of cerebrovascular accident Complicated valvular heart disease Migraine headache with focal neurological symptoms Breast cancer (current) Diabetes with retinopathy / nephropathy / neuropathy Severe cirrhosis Liver tumour (adenoma or hepatoma)

RELATIVE CONTRAINDICATIONS Smoker over the age of 35 (< 15 cigarettes per day) Adequately controlled hypertension Hypertension (systolic 140–159mm Hg, diastolic 90–99mm Hg) Migraine headache over the age of 35 Currently symptomatic gallbladder disease Mild cirrhosis History of combined OC-related cholestasis Users of medications that may interfere with combined OC metabolism

These side-effects may lead to discontinuation of the combined OC. Some combined OC users will experience minor side-effects, most commonly during the first 3 cycles. These side-effects may lead to discontinuation of the combined OC.

The most common reason patients discontinue combined OC use SIDE-EFFECTS The most common reason patients discontinue combined OC use Abnormal menstrual bleeding, Nausea, Weight gain, Mood changes, Breast tenderness, Headache.

WEIGHT GAIN Placebo-controlled trials have failed to show any association between low-dose combined COC and weight gain. Studies comparing the COC to other contraceptive methods have failed to show a significant associated weight gain.

BREAST CANCER The risk of breast cancer in combined OC users is still controversial. The research suggested that there was a small but significant increase in risk of breast cancer in women who are smokers and currently taking the combined OC and in the first 10 years after discontinuing it.

CERVICAL CANCER Long-term COC use may increase the risk of cervical cancer in women who are HPV positive but not in women who are HPV negative. Infection with HPV,as the major risk factor for cervical cancer, is related to sexual behaviour.

NON-CONTRACEPTIVE BENEFITS Decreased endometrial cancer Decreased ovarian cancer Decreased risk of fibroids, endometriosis Cycle regulation Decreased menstrual flow Increased bone mineral density Decreased dysmenorrhea Decreased peri-menopausal symptoms Decreased acne Decreased hirsutism Decreased incidence of salpingitis and PID Possibly fewer ovarian cysts Possibly fewer cases of benign breast disease Possibly less colorectal carcinoma

1. PATIENT ASSESSMENT Before prescribing a COC, a thorough history should be taken, including potential contraindications, smoking history, and medications. The physical examination should include a blood pressure measurement.

No routine laboratory screening is required. 1. PATIENT ASSESSMENT No routine laboratory screening is required. 2. Counselling

(Intra Uterine Device for contraception) I.U.D. (Intra Uterine Device for contraception)

First generation I.U.D.is Lipes loop Second generation I.U.D. is Copper T-200 Third generation Gyne-T 380 With 8 years Intra uterine life

Levonorgestrel Forth generation I.U.D. MIRENA Jaydess A capsule on the Stem contain mixture Of silicon rubber & 60mg of progestin 60mg Levonorgestrel Developed by steroid research Laboratory-Finland releasing 20mcg per day estimated to last 5 years. Forth generation I.U.D.