Contraception

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					Contraception


     Dr. Fariha Farooq FCPS
   Assistant Prof. Obs & Gynae
Akhter Saeed Medical & Dental College
           Lahore Pakistan
Contraception

  We use our knowledge of
  reproductive physiology to
  promote or avoid
  pregnancy.
Contraception

     Three general strategies:
      – Prevent ovulation;
      – Prevent fertilization;
          Keep    sperm & oocyte away from each
          other.
      – Prevent implantation.
Contraceptive methods
  Hormonal methods
  Barrier methods
  Intrauterine devices
  Natural methods
  Permanent methods
Hormonal Methods
    Oral Contraceptives
     (Birth Control Pill)
    COCP
    PROGESTIN ONLY PILL
  Injections (Depo-Provera)
  Implants (Norplant I & II
  Patches
  Vaginal rings
  Hormone releasing IUCD
Hormonal Prevents ovulation
           Thickens mucus at the cervix so
           sperm cannot pass through
           Changes the environment of
           the uterus and fallopian tubes
           to prevent fertilization or
           implantation should
           fertilization occur
Hormonal Contraception:
Combination OCP’s
  Contain Synthetic Estrogen/Progestin
  Modern E2 Dosage ≤ 50 Mcg
  Despite Diversity, Side Effects and
   Efficacies are Similar
  Requires Patient Compliance
Combination OCP’s:
Mechanism of Action
  Suppresses LH / FSH Release
   (E2     FSH, P     LH)
  Progestin Thickens Cervical Mucus and
   Alters Endometrium
  Major Effect Is Anovulation and
   Impairment of Sperm Transport and
   Oöcyte Implantation
      Contraception
   Prevent ovulation.
    – “The Pill”
        Synthetic “progestins” mimic
         effect of progesterone.
        Inhibits FSH & LH, and their
         effects on follicle
         development
    – Norplant
    – Depo-provera
Combination OCP’s:
Additional Benefits
  Menstrual Regulation
  Decreased Risk of Anemia
  Ovarian, Endometrial CA:    Risk
  Lower PID Risk
  Prevention of Benign Breast Disease
Combination OCP’s:
Side Effects
  Breakthrough Bleeding (≤ 25%)
  Amenorrhea
  Breast Tenderness, Nausea
  H/A (+/–)
  ?HTN
  ?Weight Gain
Combination OCP’s:
Risks
  Thromboembolism (Greater if ≥ 35 y/o
   and Smoker)
  MI (Smokers Only):
     – < 15 cig/day: 3X Risk
     – > 15 cig/day : 21X Risk
    Liver Adenomas (Very Rare)
Depo-Provera:
  Inhibits Ovulation
  150 mg q 3months (14 day grace
   period)
  Delayed Ovulation After Discontinuation
  Main Side-Effects:
     – Amenorrhea
     – AUB
     – Weight Gain
     – Hair Loss
Norplant:
  Implantable for ≤ 5 Years
  Similar Side Effects as Depo-Provera
  Avg. Yearly Failure Rate: 0.8/100
   (Increases : > 2/100 after 5 years)
  Occasionally Difficult to Remove
Barrier methods   Block sperm from
Male / Female    reaching the egg
condom
                  Some are used
 Diaphragm
                  with spermicides,
                  which kill sperm.
Barrier Methods:
 Diaphragm: High Failure Rates
  – Must Remain in ~6 Hrs post-coitus
  – Best if Combined with Spermicide
  – UTI Potential
 Condom: STD Protection, Inconsistent
  Use by Men
 Female Condom: Cumbersome,
  Learning Curve
 IUCD(Intrauterine contraceptive
device)
 •COPPER-T


 •MULTILOAD


 •MIRENA (progestin
 releasing IUCD)
MIRENA
               The progestin released by the
Intrauterine   levonorgestrel (LNg) IUD prevents
device (IUD)   fertilization by making the mucus in
               the cervix thick and sticky, so sperm
 COPPER-T
               can't get through to the uterus. The
 MULTI LOAD   progestin and IUD change the uterine
 MIRENA       lining, preventing implantation in the
               rare case that fertilization occurs.


               The copper in the copper IUD is toxic
               to sperm. It causes changes in the
               uterus and fallopian tubes that kill
               sperm
IUD:
Mechanisms of Action
  NOT ABORTIFACIENT!!!!!!!!
  Prevents Conception:
   – Sperm Transport Inhibited
   – Sperm Survival / Capacitation
      Diminished
  Prevents Implantation: hCG Levels = 0
IUD:
Complications
  PID: Usually 20 Insertional Contamination
   – Unproven Role for Prophylactic ABx
  Hypermenorrhea
  Expulsion
  Perforation (< 0.1%)
  Failure: IUD Should be Removed
  ??Ectopic
Fertility         Identifies the time
                  during a woman's cycle
awareness
                  when she is most likely
(natural family   to become pregnant
planning)         (fertile). An additional
                  method or abstinence
                  should be used during
                  this time of fertility.
      Contraception

   Prevent fertilization.
    – Coitus interruptus
       Least effective of all
    – Rhythm
       50% failure rate
        Avoid   intercourse
         during woman’s likely
         fertile period
        ~ 1 week before
         ovulation to ~ 4 days
         after ovulation
Fertility Awareness Methods

Basal Body Temperature Method
(BBT)
The lowest body temperature of a
healthy person during awaking hours
                              OVULATORY
                              CYCLE
                              BBT IS
                              BIPHASIC
Permanent birth control (sterilization)

Men: Vasectomy          Women: Tubal ligation
blocks the release of   surgery or tubal
sperm.                  implants block the
                        movement of an egg
                        through the fallopian
                        tube, preventing
                        fertilization.
Emergency Contraception

            IUCD, OCP’s
  Specific OCP Regimens Given ≤ 72
   Hours After Unprotected Intercourse
   ~ 75% Effective
  Yuzpe Method: Ovral 2 tabs po now and
   2 tabs 120 later
  Progestin only pills 2tabs stat
  IUCD can be inserted up to 5 days after
   unprotected intercourse
Efficacy (modified from trussell, et. al 1990)
Failure Rate (Percent) During First Year of Use
                                          6
  6

  5

  4
         3
  3
                                                     2
  2
                                                                       0.8
  1                           0.5
                                                             0.3                             0.2
                    0.1                                                           0.04
  0
      Spermicides   Comb.   Prog. OCP's Diaphragm   Condom    Depo-    Cu-T380A   Norplant    TL
                    OCP's                                    Provera
IUD:
Contraindications
  Lack of Monogomy, High Risk for STD’s
  Abnormal Uterine Bleeding
  Current Pelvic Infection (GC, Chl)
  Actinomyces on Pap
  ???Nulliparity
  Pregnancy
  Wilson’s Dz, Cu Allergy (both rare)
Special Circumstances
  Postpartum/Postabortion:
   – IUD, Progestins, Combination OCP’s*
  Anticonvulsant/Antibiotic Use:
   – TCN Probably OK
   – Most Anticonvulsants Impair Efficacy
      of Hormonal Contraceptives


* may affect lactation before milk flow established
THANK YOU

				
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