contraception

 Pregnancy rates at 1 year approach 90 percent for sexually active fertile

women who do not use contraception.
 Because ovulation often precedes menstruation, young women should
be advised to use contraception whenever they begin sexual activity.
 Providing contraceptive advice for the woman nearing menopause is
harder, because it is difficult to predict when fertility has ended.
 Contraceptive Methods

 Oral steroidal contraceptives

 Injected steroidal contraceptives
 Intrauterine devices
 Transdermal and transvaginal steroidal contraceptives
 Physical, chemical, or barrier techniques
 Sexual abstinence around the time of ovulation
 Breast feeding
 Permanent sterilization
 Hormonal Contraceptives

 Pill -Combination oral contraceptives (COCs)-

consist of a combination of estrogen and progestin,
 Mini pill (consist of a progestin)
 Injection,
 Transdermal patch,
 Implant,
 Transvaginal ring.
 Oral contraceptives
These typically consist of a combination of an estrogen and a progestational agent
Taken daily for 3 weeks and then stopped for 1 week,
Longer durations of active hormone administration, designed to minimize
withdrawal bleeding.
The most important effect is to prevent ovulation by suppression of hypothalamic
gonadotropin-releasing factors, which in turn prevents pituitary secretion of follicle-
stimulating hormone (FSH) and luteinizing hormone (LH).
Estrogen suppresses FSH release and stabilizes the endometrium to prevent
metrorrhagia.
Progestins inhibit ovulation by suppressing LH, they thicken cervical mucus to
retard sperm passage, and they render the endometrium unfavorable for
implantation.
ovulation suppression, inhibition of sperm migration, and creation of an unfavorable
endometrium for implantation. Thus, combined oral contraceptives, if taken daily for
3 out of every 4 weeks, provide virtually absolute protection against conception.
 Beneficial Effects
of COCs
 Increased bone density
 Reduced menstrual blood loss and anemia
 Decreased risk of ectopic pregnancy
 Improved dysmenorrhea from endometriosis
 Fewer premenstrual complaints
 Decreased risk of endometrial and ovarian cancer
 Reduction in various benign breast diseases
 Inhibition of hirsutism progression
 Improvement of acne
 Prevention of atherogenesis
 Decreased incidence and severity of acute salpingitis
 Decreased activity of rheumatoid arthritis
 Side effects
 Lipids and Lipoproteins –
 COCs increase serum triglyceride and total cholesterol levels.
Estrogen decreases concentration of low-density lipoprotein (LDL) cholesterol and
increases high-density lipoprotein (HDL) cholesterol.
 Carbohydrate Metabolism -Concern over deterioration in glucose tolerance,
mediated principally by the progestin, is no longer warranted with current
formulations. COCs do not increase the risk of diabetes Combination oral
contraceptives may be used in women who have diabetes not complicated by
associated vascular disease.
 Protein Metabolism -Estrogens increase hepatic production of a variety of
globulins. Increased angiotensinogen production appears to be dose related, and
its conversion by renin to angiotensin I has been suspected to be associated with
so-called pill-induced hypertension (Hypertension). Fibrinogen, and likely factors II,
VII, IX, X, XII, and XIII, are increased in direct proportion to estrogen dose . The
incidences of both forms of thrombosis appear to be estrogen-dose related.
 Side effects
Liver Disease -Cholestasis and cholestatic jaundice are uncommon complications of
oral contraceptives. If they develop, signs and symptoms clear when the COCs are
stopped.
Neoplasia -A stimulatory effect on some cancers is always a concern with female
sex steroids.
Liver Cancer -contraceptives with larger estrogen doses were linked
circumstantially with hepatic focal nodular hyperplasia and benign hepatic adenoma.
low-dose oral contraceptives do not support such an association .
Prolonged oral contraceptive use with hepatocellular carcinoma.
Cervical Cancer-There is a correlation between the risk of cervical dysplasia and oral
contraceptive use, and the the risk of cervical cancer increases after 5 years.
Breast Cancer- Current data neither support nor refute an association
between COCs and ovarian or breast cancer among women heterozygous
for BRCA1 and BRCA2 genes.
Nutrition- Lower plasma levels are reported for ascorbic and folic acid, vitamin B 6
(pyridoxine) and vitamin B12, niacin, riboflavin, and zinc.
 Cardiovascular Effects

Thrombosis and Embolism

Stroke
Hypertension
Myocardial Infarction
 Side effects
Effects on Reproduction -Postpill amenorrhea after combination hormonal
contraception discontinuation likely reflects a pre-existing problem. At least
90 percent of women who previously ovulated regularly will do so within 3
months after discontinuance of oral contraceptives.
Lactation -
 There are limited data on the interaction of COCs and lactation. Minute
quantities of the hormones are excreted in the breast milk, but no adverse
effects on infants have been noted.
 Because progestin-only oral contraceptives have little effect on lactation,
they are preferred for up to 6 months in women who are exclusively
breast feeding (Oral Progestins).
 Those who are only intermittently breast feeding should use effective
contraception beginning as soon as 3 weeks postpartum.
Weight Gain
 Other Effects

Cervical mucorrhea- the mucus at times may be irritating to the vagina and vulva.
Vaginitis or vulvovaginitis, especially that caused by Candida species, also may
develop.
Hyperpigmentation of the face and forehead— known as chloasma—is more
likely in women who demonstrated such a change during pregnancy.
Uterine leiomyomas -do not increase in size with oral contraceptive use . Low-
dose estrogen formulations are not associated with depression, and indeed, may
cause it to improve .
Hormonal contraception does not prevent the transmission of HIV infection or any
other viral infection.
Risk of Death --Mortality associated with oral contraceptives is rare if a woman is
younger than 35, has no systemic illness, and does not smoke.
Postpartum Use- Women who do not breast feed may ovulate before 6 weeks
after pregnancy. To starting oral contraceptives before the traditional 6-week
postpartum examination.
 Contraindications: Combination contraceptives should not be used in
women with:

 Thrombophlebitis or thromboembolic disorders

 History of deep vein thrombophlebitis or thrombotic disorders
 Cerebrovascular or coronary artery disease
 Thrombogenic cardiac valvulopathies
 Thrombogenic heart arrhythmias
 Diabetes with vascular involvement
 Severe hypertension
 Known or suspected breast carcinoma
 Carcinoma of the endometrium or other known or suspected estrogen-
dependent neoplasia
 Undiagnosed abnormal genital bleeding
 Cholestatic jaundice of pregnancy or jaundice with pill use
 Hepatic adenomas or carcinomas or active liver disease with abnormal liver
function
 Known or suspected pregnancy
 Major surgery with prolonged immobilization
 Transdermal Administration

 The combined contraceptive approved patch is applied to the buttocks, upper outer
arm, lower abdomen, or upper torso but avoiding the breasts.

 It delivers 150 g of the progestin, norelgestromin, and 20 g of ethinyl estradiol daily.

A new patch is applied each week for 3 weeks, followed by a patch-free week to
allow for withdrawal bleeding.

 The benefits, risks, and contraindications of the transdermal contraceptive patch

are generally similar to those of combined hormonal oral contraceptives. Both
methods offer highly effective, reversible, noncoital-based contraception, but are
subject to adverse estrogen-related side effects.
 However, transdermal hormonal contraceptive
systems offer several potential advantages to oral
contraceptive pills:

 Therapeutic effects are achieved at lower peak doses since first-pass hepatic
metabolism and enzymatic degradation in the gastrointestinal tract are avoided.
 Plasma hormone levels remain constant (peaks and troughs do not occur).
 Sustained drug delivery reduces the need for frequent self-administration, and thus
may improve patient compliance.
 The nonoral route of administration is useful for patients who have difficulty
swallowing pills.
 Immediate cessation of drug administration is possible with removal of the
transdermal system.
 Although data are limited, there is a possibility of an increased risk of venous
thromboembolism (VTE) in patch users compared to users of estrogen-progestin
oral contraceptives.
 Transvaginal Administration

 INTRODUCTION — Combined (estrogen-progestin) hormonal

contraception is a popular method of contraception worldwide and is
highly effective when used consistently and correctly.
 Its a flexible polymer ring with an outer diameter of 54 mm and an inner
diameter of 50 mm .
 Its core contains ethinyl estradiol and the progestin, etonogestrel, which
are released at rates of 15 g and 120 g per day, respectively.
 Although this results in serum hormone levels lower than comparable
low-dose oral contraceptives, ovulation inhibition is complete.
 The contraceptive vaginal ring offers the same benefits as oral
contraceptives (OCs), but has the advantage that daily user compliance is
not required.
 The ring is left in place for three weeks and then removed for a single
ring-free week
 Intramuscular Administration

 There is only one combination preparation for intramuscular injection.

 This contraceptive contains 25 mg of medroxyprogesterone acetate plus 5 mg of
estradiol cypionate.
 One injection is given monthly.
 The drug inhibits ovulation and suppresses endometrial proliferation .
 Serum estradiol values reach a peak level by 3 to 4 days postinjection and then
decline, leading to withdrawal bleeding 20 to 25 days after injection .
 Progestational Contraceptives
Oral Progestins -Progestin-only pills, also known as mini-pills, are taken daily.
Unlike COCs, they do not reliably inhibit ovulation.
Rather, their effectiveness depends more on cervical mucus alterations and
effects on the endometrium.
Because the mucus changes do not persist beyond 24 hours, to be maximally
effective it should be taken at the same time every day.
These contraceptives have not achieved widespread popularity because of a
much higher incidence of irregular bleeding and a slightly higher pregnancy rate
than combination contraceptives
Progestin-only pills have minimal if any effect on carbohydrate metabolism or
coagulation, and they do not cause or exacerbate hypertension.
They may be ideal for some women who are at increased risk of cardiovascular
complications.
Mini-pill is often an excellent choice for lactating women.
In combination with breast feeding, it is virtually 100-percent effective for up to 6
months and does not impair milk production.
 Progestational Contraceptives

 Injectable Progestin Contraceptives- Depo-

Provera

 Progestin Implants-levonorgestrel
 Hormonal Emergency Contraception

Estrogen-Progestin Combinations

Progestins Only
 Mechanical Methods of Contraception

Intrauterine Contraceptive Device

 Intrauterine Contraceptive Device

At one time in the United States, approximately 7 percent of

sexually active women used an intrauterine device (IUD) for
contraception.
The two devices currently approved for use:
 Copper-containing ParaGard
 and levonorgestrel-containing Mirena
 Types of Devices

Levonorgestrel-Containing Intrauterine Device

The Mirena device releases levonorgestrel into the uterus at a relatively constant rate
of 20 g/d, which reduces the systemic effects of the progestin. It is a T-shaped
polyethylene structure that has its stem wrapped with a cylinder made of
polydimethylsiloxane and levonorgestrel. A permeable membrane surrounds the
mixture to regulate the rate of hormone release. A monofilament brown polyethylene
thread is attached to a small loop at the distal end of the device's vertical body.

Copper-Containing Intrauterine Device

The ParaGard T 380A device is composed of polyethylene with barium sulfate.

 Spermicides and Microbicides

These contraceptives are marketed variously as creams, jellies, suppositories,

film, and foam in aerosol containers. They are used widely in this country,
especially by women who find other methods unacceptable. They are useful
especially for women who need temporary protection.

Spermicides work by providing a physical barrier to sperm penetration as

well as a chemical spermicidal action. The active ingredient is nonoxynol-9
or octoxynol-9.
Spermicides must be deposited high in the vagina in contact with the
cervix shortly before intercourse. Their duration of maximal effectiveness is
usually no more than 1 hour.
 Female Sterilization

These techniques, including any modifications, basically consist of:

1. Ligation and resection at minilaparotomy, as described earlier for puerperal
sterilization (Interval Partial Salpingectomy).

2. The application of a variety of permanent rings or clips to the fallopian

tubes, usually by laparoscopy (Laparoscopic Sterilization).

3. Electrocoagulation of a segment of the oviducts, also usually through a

laparoscope ( Laparoscopic Sterilization).
 Male Sterilization

Through a small incision in the scrotum, the lumen of the vas deferens is
disrupted to block the passage of sperm from the testes. With local
analgesia, the procedure is usually performed within 20 minutes.