1. Contraception
د. ياسمين حمزة

2. 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.

3. 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.

4. 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 .

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14.  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.

15. 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.

16. 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.