METHODS OF

CONTRACEPTION Aboubakr Elnashar Benha University Hospital, Egypt

I. Hormonal Methods

II. Intrauterine Device

III. Barrier Methods

IV. Natural Methods

V. Sterilization

Outline

I. Hormonal Methods

Advantages

Most effective, long-term reversible contraception available

Most methods offer complete privacy

Require no planning before intercourse

Disadvantages

Require a visit to a healthcare professional

May cause common hormonal side effects

Products containing estrogen may be associated with rare, but serious health risks

Not effective against STD

Daily Use

Oral Contraceptive Pill

– Combination pill

– Progestin-only pill

Nondaily Use

Injectable contraceptive

Contraceptive patch

Hormone-releasing

intrauterine system

Emergency Contraception

1. The Combination Pill

Contain Synthetic Estrogen/Progestin

Modern E2 Dosage ≤ 50 Mcg

Despite Diversity, Side Effects and Efficacies

Similar

Requires Patient Compliance

May Be Monophasic or Triphasic

Estrogens:

Ethinyl estradiol

Mestranol

Progestins:

Ethynodiol diacetate

Norethindrone acetate

Norethindrone

Norgestrel

Levonorgestrel

Desogestrel

Norgestimate

Drospirenone

2nd Generation

3rd Generation

Spironolactone Derived

Advantages:

Highly effective

Provides noncontraceptive health benefits

Private

Does not require vaginal insertion

Allows to control cycle

Disadvantages:

Must be taken daily

Side effects may lead to discontinuation

Associated with rare, but serious health risks, such as blood clots and stroke

Non-Contraceptive Benefits of OCPs

Improvement

Dysmenorrhea

Acne

Hirsutism

Anemia

Cycle Regulation

Reduction Risks

Colorectal Cancer (18-40%)

Endometrial Cancer

PID (10 – 70%)

Osteoporosis

Osteopenia

Cleveland Journal of Medicine 2004

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

Side Effects

Breakthrough Bleeding (≤ 25%)

Amenorrhea

Breast Tenderness, Nausea

? HTN

? Weight Gain

Risks

Thromboembolism (≥ 35 yo, Smoker)

MI (Smokers Only):

< 15 cig/day: 3X Risk

> 15 cig/day : 21X Risk

Liver Adenomas (Very Rare)

2. The Contraceptive Patch (Evra Patch)

Advantages:

Efficacy comparable to OCPs

Weekly application encourages compliance

Does not require vaginal insertion

Disadvantages:

Application site reactions may occur

May not be as effective in women weighing more than 198 pounds

May produce side effects similar to OCPs, with higher rate of transient breast pain

Noncontraceptive health benefits theoretically similar to combination OCPs, but not as well documented

May be visible on the skin

OCP = Oral Contraceptive Pill

3. The Progestin-Only Pill

Progestins:

Norethindrone

Norgestrel

Advantages:

Useful for women with contraindications to estrogen

Use with postpartum women who are breastfeeding

Does not require vaginal insertion

Disadvantages:

Higher pregnancy rate than combination OCPs

More sensitive to missed pills than combination OCPs

Associated with abnormal bleeding and other side effects

4. Injectable Hormonal Contraception

Advantages:

Highly effective

Convenient three month administration schedule encourages adherence

Private

Useful when estrogen should be avoided

Decreases risk of endometrial cancer

Disadvantages:

Irregular bleeding and amenorrhea frequently occur

Weight gain, abdominal pain, and depression are common side effects

Prolonged use may decrease bone mass

Depo Provera:

-every 3 months

-Medroxyprogestin

Acetate 150 mg.

Types

Main Side-Effects:

Amenorrhea

AUB

Weight Gain

Hair Loss

5. Emergency Contraception Indications -standard of care for women not protected by efffective contraception. -No contraception was used -Condom broke, slipped, leaked etc…. -Missed more 2 or more days of ocp’s

-Highly effective 75%

-Effective up to 120 hours after unprotected sex -Will not disrupt or harm developing pregnancy

J Adolesc Health. 2004;35:66-70.

FDA Approved Emergency Contraceptive Kits

PREVEN KIT

- Contains 4 pills

- EE 50 ug.

- Levonorgestril

0.25 mg.

- 2 pills 12 hourly

for 2 doses

Plan B Kit

- contains 2 pills

- Levonorgestril

0.75 mg

- 1 pill 12 hourly for

2 doses

The Yuzpe Regimen:

Two Doses of:

EE 0.1 mg with

dl-norgestrel 1.0 mg

Administered 12

hours apart

First dose taken within 120

hours of unprotected

intercourse

The Combination Pill

Advantages:

Prevents approximately 75% of unintended pregnancies

Disadvantages:

Increased incidence of side effects due to high estrogen component

High rate of nausea (50%) and vomiting (20%) may limit adherence

EE = Ethinyl Estradiol

The Progestin-Only Pill

Advantages:

More effective than Yuzpe regimen

Better tolerated than Yuzpe regimen

May be taken as a single dose

May be preferable for women with history

of idiopathic thrombosis

Disadvantages:

Associated with a moderate degree of side

effects including nausea, vomiting,

dizziness, and fatigue

Plan B (levonorgestrel 0.75 mg)

Levonorgestrel:

Single dose of 1.5 mg or two doses of 0.75 mg taken 12 hours apart

First dose administered within 120 hours

ACOG GUIDELINES (Emergency Contraception)

-Should be offered or made available for (UPSI)

- Levonorgestril only regime is more effective &

less side effects than combined regime

- 1.5 mg Levonorgestril can be taken single dose

or 2 divided doses (0.75 mg) 12-24 hrs. apart

- An anti-emetic can be taken 1 hr before 1st dose

- Prescription of EC in advance can increase

availability and use.

II. IUD

ParaGard (CuT380A),

Very Effective (~ TL), Reversible

Risks OVERBLOWN

Does Not Protect Against STD’s

Can Remain for ≤ 10 Years

Mechanisms of Action

NOT ABORTIFACIENT!!!!!!!!

Prevents Conception:

– Sperm Transport Inhibited

– Sperm Survival / Capacitation

Diminished

Prevents Implantation: hCG Levels = 0

Work-up

History: STD’s, Sexual History, Ectopic

PEx: Size / Configuration of Uterus

Cervical Cultures, Pap

Counseling

Contraindications

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)

Complications

PID: Usually 20 Insertional Contamination

– Unproven Role for Prophylactic ABx

Hypermenorrhea

Expulsion

Perforation (< 0.1%)

Failure: IUD Should be Removed

??Ectopic

1. The Copper Intrauterine Device (IUD)

Advantages:

Highly effective

May be efficacious if inserted up to 7 days after intercourse

Generally well tolerated

Disadvantages:

Not cost effective for short-term use

Not recommended for women with a sexually transmitted disease

2. Multi load with IUCD inserter

3. Levonorgestrel Intrauterine System

Advantages:

Highly effective

Stays in place for up to five years, limiting adherence concerns

Private

Decreases menstrual blood loss

Disadvantages:

Requires professional insertion and removal

Abnormal bleeding, dysmenorrhea, and pelvic, abdominal and back pain

May not be appropriate for women with increase STD risk

III. Barrier Methods

Advantages

- Preferred by many who have occasional intercourse

- Useful alternatives for those who want to avoid hormonal side effects

- Some methods available without prescription

- Some methods offer limited protection against sexually transmitted disease

Disadvantages

-Not as effective as hormonal methods

-Efficacy is highly dependent on consistent and correct

use

-Require fitting by healthcare provider

-Require vaginal insertion and removal by the patient

that may be difficult or unacceptable

-Require concomitant use of spermicide

-Associated with an increased risk of urinary tract

infection and toxic shock syndrome

Diaphragm

Cervical Cap

Types

Male Condom

Spermicide

Advantages:

Can be inserted hours before intercourse

Does not require removal between acts of intercourse

1. Diaphragm

Disadvantages: -Should not be used with suspected or confirmed latex

allergy

-Requires prescription and fitting by healthcare provider

-Requires insertion and removal

-Spermicide must be applied before each use

-Must stay in place for at least six hours after last intercourse

-May increase risk of urinary tract infections and toxic shock

syndrome

2. Male Condom

Advantages:

Provides greater protection against STDs than any other method of contraception

Provides substantial protection against pregnancy when used with a spermicide

Does not require a prescription

Can be used with other methods

Inexpensive and widely available

Disadvantages:

Can only be used for one act of intercourse

Can break or slip during use

May decrease sexual pleasure

May interfere with spontaneity

Requires cooperation of male partner

IV. Natural Methods

1-Natural family planning techniques (Fertility Awareness Methods) 2-Contraceptive effect of breast feeding (Lactational Amenorrhea Method) 3- Withdrawal

1. Rhythm-standard days method (SDM)

For women with menstrual

cycles between 26 & 32 days.

Avoid unprotected IC day #9-

19

70-80% effective

Assumes ovulation about day

#14

2. Withdrawal Method

80-90% effective

Always available

Requires motivation,

sense of timing

Some sperm present in

pre-ejaculatory fluid

Psychological issues

V. Sterilization

Surgical sterilization

Permanent, irreversible

>99% effective

METHODS OF TUBAL LIGATION Procedure Timing Technique

Minilaparotomy •Post Partum

•Post Abortion

•Interval

•Mechanical Devices

(Clips, Rings)

•Tubal Ligation or Excision

Laparoscopy •Interval Only

•Electrocoagulation

(Unipolar, Bipolar)

•Mechanical Devices

(Clips, Rings)

Laparotomy In conjunction with other surgery (cesarean section, salpingectomy, ovarian cystectomy etc.)

•Mechanical Devices

(Clips, Rings)

•Tubal Ligation or Excision Female Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-160

Pomeroy Procedure Tied

Cut

Final result

Filshie Clip

Hulka Clip

Monopolar Coagulation

Laparoscopic

•Proposed in 1937 by Anderson

•Complications

•Bowel Burn

•Longer portion of

tube is damaged

•Failures and ectopic

pregnancy

1. Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8

Failure Rate:7.5/1000

Bipolar Coagulation Laparoscopic

Introduced in 1973 by Jacques Rioux

Benefits

•Most Common method

of Laparoscopic

sterilization

Complications

•Formation of uteroperitoneal fistulas

•High rate of Ectopic Pregnancy

•Potential for Bowel Burns

•Reversals are potentially more difficult due to the extent of tube damage

1. Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170

Failure Rate:24.8/10001