2.  3 million women suffer significant perminant disabilities.  Many STD can be prevented by contraception. (HIV )infection.

3. the ideal contraceptive method should: 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 personel.

4.  Many unintended pregnancies still occur in a women who are using contraception but are not using their chosen method correctly.

5. 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 for1 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.

6. typical use perfect use method 85% No method 0.15% 0.10%Male sterilization 0.5% Female sterilization 0.8% 0.6%Copper T IUD 0.1% Levonorgestrel IUD 6.7% 0.3%DMPA

7. 8.7% 0.3%OC-combined 8.7% 0.5%OC-progesterone only 16% 6%Diaphragm +spermic 17% 2%condom 32% 26%Cervical cap parous 16% 9%Cervical cap nullip 29% 15%spermicides 18.4% -Withdrawal

8. Method of contraception tier Progesterone implant,IUDLonger term Depot medroxy prog acetate inj. Vaginal rings,transdermal patches,oral contraceptice pills. Malecondom,diaphragm,caps,fe male condom,sheild,spermicide,withdrawal,fertility awarwness method,natural family planning. Combined hormonal Barrier and behavioral methods

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

10. Perminant methods[sterilization] Female tubal occlusion Male vasectomy

11. first licensed in the UK in 1961. It contains a combination of two hormones: a synthetic oestrogen and progestogen available as once daily pill. 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

12. Combined oral contraceptive pills contains both: 1-Synthetic Estrogen (Ethinyl estradiol mostly): The dose of oestrogen varies from 50 to 15 μg. 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

13.  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..

14. For maximum effectiveness, COC 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 should always be taken regularly at roughly the same time each day. Other are for extended cycle use to eliminate or minimize the number of scheduled bleeding episode induced by placebo pills.this scheduled bleeding is not medically indicated but desired by some women for personal reason.

15. 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 of both 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

16. 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 FSH and LH, which prevents follicular development within the ovary and therefore ovulation. Peripheral effects include - Making endomtrium atrophic and hostile to an implanting embryo - altering cervical mucus to prevent sperm ascending into the uterine cavity.

17. 1 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 2 Acute or severe liver disease 3 Oestrogen-dependent neoplasms, particularly breast cancer 4.Breastfeeding <6 weeks post-partum 5.Smoking ≥15 cigarettes/day and age ≥35 6.Focal migraine

18. Relative contraindications Generalized migraine Long-term immobilization Irregular vaglinal bleeding (until a diagnosis has been made) Less severe risk factors for cardiovascular disease,e.g. obesity, heavy smoking, diabetes

19. 1-Venous thromboembolism: VTE is the major measurable risk other wise the combined oral contraceptive pills are very safe. 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.

20. The risks of VTE are: 5 per 100 000 for normal population, 5 per 100 000 for normal population, 15 per 100 000 for users of 2 nd generation. 30 per 100 000 for users of 3 rd generation. 30 per 100 000 for users of 3 rd generation. 60 per 100 000 for pregnant women.

21. 2-Arterial disease *risk of hypertention: 1 per cent of COC users will become significantly hypertensive and they should be advised to stop taking COC *risk of myocardial infarction and thrombotic stroke : stroke : in young, healthy women using low-dose COC is extremely small. Cigarette smoking Cigarette smoking will, however, increase the arterial risk, and any woman who smokes must be advised to stop COC at the age of 30years.

22. 3-Mortality There is increased mortality in women using the pills over women not using it, 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 nor have hypertention or diabetes have no exess mortality otherwise women over 35 years,women who Smoke or have hypertention there is excess mortality.

23.  Breast cancer 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 their forties, these are more relevant data, as the background rate of breast cancer is Higher, but beyond 10 years after stopping coc there was no increase in breast cancer risk for former coc users.

24.  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

25. CNS 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

26.  Method of use  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

27. 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

28. 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.

29.  *Steroids,Ascorbic acid (Vitamin C) and acetaminophen may elevate plasma ethinyl estradiol so increase its efficacy.

30. Positive health benefits *COC users generally have light, pain -free, regular bleed and therefore COC can be used to treat heavy or painful periods ( 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.

31. 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.

32. Combined hormonal patches A contraceptive transdermal 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. Contraceptive patches have the same risks and benefits as COC and, although they are relatively more expensive, may have better compliance.

33. All other types of hormonal contraception in current use in the world are progestogen - only and share many similar features in terms of mode of action and side effects. Because they do not contain oestrogen, they are extremely safe & can be used if woman has cardiovascular risk factors. The dose of progestogen within them varies from very low to high

34. progestogen-only pill, or 'mini-pill' subdermal implant Implanon® injectables. hormone-releasing intrauterine system

35. 1-peripheral effects: *local effect on cervical mucus making it hostile to ascending sperm. *Local effect on the endometrium making it thin & atrophic thereby preventing implantation *Progestin use also causes decreased tubal and endometrial motility. 2-central effects Higher dose progestogen-only methods can act centrally & inhibit ovulation.

36.  Menstrual disturbances either irregular vaginal bleeding or amenorrhea.  Functional ovarian cyst  Increase risk of ectopic pregnancy :this has not been confirmed,although it is probably that POP protect much more effectively against intrauterine than ectopic pregnancy.

37. The progestogen-only pill (POP) is ideal for Women who like the convenience of pill taking but cannot take COC. Although the failure rate of the POP is greater than that Of COC, it is ideal for women at times of lower fertility. If the POP fails, there is a slightly higher risk of ectopic pregnancy

38. they contain *the second-generation progestogen norethisterone or norgestrel (or their derivatives) *or the third-generation progestogen desogestrel. The POP is taken every day without a break

39. Particular indications for the POP include: breastfeeding older age cardiovascular risk factors diabetes.

40. Two injectable progestogens are marketed. Depot medroxyprogesterone acetate 150 mg (Depo-Provera or DMPA) which lasts around 12-13 weeks. Norethisterone enanthate 200 mg (Noristerat) which only lasts for 8 weeks and is not nearly so widely used.

41. Depo-Provera is a highly effective method Of contraception and it is given by deep intramuscular injection Most women who use it develop very light or absent menstruation. Depo-Provera will improve PMS and can be used to treat menstrual problems such as painful or heavy periods. It is particularly useful for women who have difficulty remembering to take a pill

42. weight gain of around 3 kg in the first year, delay in return of fertility - it may take Around 6 months longer to conceive compared to a woman who stops COC, persistent menstrual irregularity,irregular vaginal bleeding may occur or amenorrhea in prolonged use of this injection very long-term use may slightly increase the Risk of osteoporosis (because of low oestrogen levels)

43. This injection can be given Within five days after the onset of menses. within 6 weeks after delivery if breast-feeding infant. Also it can be used after having an abortion

44. Particular indications for depo provera - contraindication to estrogen -Following rubella vaccination in peurperium. -Husband waiting for effect of vasectomy. -Mental retarded women.. -Breast-feeding. -population control in developing countries.

45. Implanon consists of a single silastic rod that is inserted subdermally under local anaesthetic into the upper arm. It releases the progestogen etonogestrel 25-70 Mg daily (the dose released decreases with time), which is metabolized to the Third-generation progestogen desogestrel. Implanon was introduced into the UK in the late 1990s. Other type of implant is the six-rod implant, Norplant, which is withdrawn from the market

47. It lasts for 3 years and thereafter can be easily removed or a further implant inserted. Implanon is particularly useful for women who have difficulty remembering to take a pill and Who want highly effective long-term contraception. There is a rapid return of fertility when it is removed.

49. IUDs can be classified as either: v Medicated, copper-bearing T380A(copper T IUD) levonorgestrel hormone-releasing (LNG-IUD) v Unmedicated, or inert The majority of the IUDs now widely used are copper-bearing.

50. This IUD provides excellent pregnancy protection that is convenient and rapidly reversible. 1 st year failure rates are 0.7% and cumulative 10- to 12-year pregnancy rate are 1.4% to 1.9%. most women are candidate for IUD use including those with serious medical problems as Hypertension, morbid obesity, diabetes, stroke,MI, and even cancer.

51.  Induce inflammatory reaction within the endometrium make the cavity and tube fluid that is toxic to the sperm,oocyte and the embryo,  Copper ions released from copper IUD reach a level in the uterine cavity fluid that is toxic to the sperm oocyte and embryo.  It appear that IUD mainly interfere with the fertilization, that’s only few sperms reaching the fallopian tube by cervical mucos hostility and by interfering with sperm motility,and affecting tubal motility, and if reaching are incapable of fertilization, even the oocyte is incapabale to be fertilized.  IUD interfere with sperm motility, oocyte capability of fertilization and implantation.

52. q Increased menstrual bleeding, often with pain, is the most common problem of IUD use and the most common medical reason for removing lUDs q Older women and women with children generally have lower rates of removal due to bleeding and pain.

53. n Unlike other IUDs, hormone-releasing devices decrease menstrual blood flow or, may even stop menstruation altogether n With all IUDs, abnormal bleeding and pain may be due not to the IUD itself but to pelvic inflammatory disease (PID), ectopic pregnancy, malignancy, or other conditions

54. ] IUD use has not been proved to induce clinical anemia ] In a study of the TCu-380Ag carried out in several developing countries and the US, the proportion of women with anemia rose only from 24% to 25.4% during four years of use

55.  Many studies have confirmed that the risk of infection and infertility among IUD users is very low (2004). However, studies also indicate that the insertion process and not the IUD or its strings, pose the temporary risk of infection.  Good infection prevention procedures should be practiced.  Antibiotic prophylaxis should not be used routinely prior to insertion.  The risk of infection following IUD insertion returns to a very low or normal level after 20 days (1992).

56.  Perforation of the uterus occurs when the IUD, the inserter tube, the sound, or another gynecological instrument used during insertion pierces the uterine muscle wall, most often at the fundus, or top of the uterus  Careful insertion technique can prevent most perforations

57.  Perforations may go unnoticed at the time of insertion  Over time lUDs may become embedded in the uterine wall without perforating it

58.  After IUD insertion, uterine contractions can push the device downward, causing partial or complete expulsion  Most expulsions occur in the first year and especially the first three months after insertion

59.  Younger women and women who have never been pregnant or have never had children are more likely to expel their lUDs  Women who had painful menstruation or abnormally large menstrual flows were more likely to expel copper-T IUDs  Correct insertion, with the IUD placed up to the fundus, is thought to reduce the chances of expulsion

60.  If pregnancy does occur, potentially severe complications can result. Medical attention is always needed  Spontaneous abortion is the most frequent complication of pregnancy with an IUD in place  the IUD should be removed as soon as pregnancy is confirmed

61.  An IUD left in place during pregnancy also increases the risk of premature delivery. It does not increase the risk of other complications-birth defects, genetic abnormalities, or molar pregnancy

62. y Mounting evidence indicates that most lUDs help to protect against ectopic pregnancy while they are in use y IUD users were half as likely to experience ectopic pregnancies as women using no contraception

63. k A recent analysis of randomized trials found that second-generation copper lUDs and the LNG-20 reduce ectopic pregnancy rates to 10% of the level among women using no contraception k lUDs provide less protection against ectopic pregnancy than consistently used oral contraceptives or barrier methods

64. w Any pregnancy in an IUD user is uncommon, however. The ectopic pregnancy in an IUD user is rare w TCu-380A and MLCu-375, have the lowest ectopic pregnancy rates – 0.25 and close to 0 per 1,000 woman years

65. Clinical implications: k Women using lUDs should be told about the signs of ectopic pregnancy k If an IUD user conceives or shows signs of pregnancy, health care providers should always look for ectopic pregnancy A woman who has had an ectopic pregnancy can use an IUD

66.  There is no evidence that IUDs cause any type of cancer

67.  among IUD users. WHO and US researchers have/estimated about one to two deaths per 100,000 IUD users per year from infection, ectopic pregnancy, or second-trimester septic abortion.  The IUD is one of the safest family planning methods, according to estimates of annual death rates among US women using various family planning methods or no method.

68.  Nulliparity and infertility: higher rate of expulsion and discomfort,,,infertility ???  Active infection,,if IUD Increased risk of actinomyces which is recovered after removal and re insertion.  Uterine anomalies increase risk of expulsion and perforation.  gynecologic malignancy.  genital bleeding of unknown cause.  gestational trophoblastic disease.

69. The LNG IUS is made of flexible plastic The LNG IUS contains a progestin hormone called levonorgestrel which has been used in birth control pills since the 1970s The safety of levonorgestrel has been proven by clinical use also in sub- dermal implants and intrauterine systems since decades

70.  in every country LNG-IUD is approved for contracepttion with an effect comparable to sterilization with an ability for regret, and is approved for treatment of heavy prolonged menstrual bleeding,and is effective as endometrial ablation.

71. LNG IUS MECHANISMS OF ACTION Thickens cervical mucus Thickens cervical mucus Inhibits sperm function in uterus Reduces monthly growth of the lining of the uterus making periods lighter and shorter; there is no evidence that LNG IUS has any impact on implantation LNG IUS can also lessen menstrual blood loss in women who have heavy menstrual flow

72.  Use of LNG IUS makes periods lighter, shorter and less painful  Over 12 months, blood loss reduced by 80-96% in women with menorrhagia  Clinical improvement in associated anemia: Hemoglobin levels rise 1.8g/L in one year of use with LNG IUS, compared to a decrease of 1.2g/L with Copper-T.  Irregular bleeding or spotting common in first 3-6 months; 20% with amenorrhea at 12 months. Sometimes the amenorrhea rate can be higher than 20% e.g. up to 50% at 12 and 24 months of use.

73. 10+ in every 100 women are likely to experience the following: Headache Abdominal/ pelvic pain Bleeding changes Vulvovaginitis (inflammation of the external genital organs or vagina) Genital discharge 1 to 10 in every 100 women are likely to experience the following: Depression Migraine Nausea Acne Hirsutism (excessive body hair) Back pain These side effects are common among OC Pill users as well. Source: Luukkainen 1995

74. It is very rare to become pregnant while using LNG IUS However, if you become pregnant while using LNG IUS, the risk having an ectopic (extra-uterine) pregnancy is relatively increased About 1 in a 1000 women correctly using LNG IUS have an ectopic pregnancy per year. This rate is lower than that among women not using any contraception (about 3 to 5 in a 1000 women per year) Woman who have already had an extra-uterine pregnancy, pelvic surgery or pelvic infection carry a higher risk of experiencing an ectopic pregnancy

75. Post-coital contraception is any drug or device used prevent pregnancy after unprotected intercourse There are two types of emergency contraception[EC]

76. 1-Combined oestrogen&progesterone[CEP ]: Combination of 100 microgram ethinyl estradiol &0.5 mg levonorgestrel is taken twice the two doses being 12 hours apart & started within 72 hours of unprotected intercourse Nausea & vomiting are common side effects. The precise mechanism of action is not known but probably involves disruption of ovulation or corpus luteal function depending on the time in the cycle when hormonal EC is taken so it inhibit ovulation or interfere with implantation.

77. 2-Levonorgestrel alone : Levonorgestrel 0.75 mg taken twice with two doses separated by 12 hours,it may be more effective & better tolerated It has to be taken within 72 hours of an episode of unprotected intercourse and is more effective the earlier it is taken 

78. A copper-bearing IUD is highly effective post-coital contraceptive with failure rate less than 1%,used up to five days after the estimated day of ovulation.It prevent implantation &the copper exerts an embryotoxic effect The hormone-releasing IUS has not been shown to be effective for EC and should not be used in this situation

79. Copper IUD LNG IUD