CONTRACEPTION

Outline

⚫ Learning outcome of the session

⚫ Outline
⚫ Body of presentation
⚫ Outcome cover = conclusion
⚫ Questions
⚫ References
 Objectives
⚫ Understand the process of fertilization
⚫ Describe: mechanism of action, the advantages,
disadvantages, failure rates, and complications
associated with the following methods of contraception
– Sterilization
– Oral steroid contraception
– Injectable steroid contraception
– Implantable steroid contraception
– Barrier methods
– Natural family planning

To be able to choose the proper contraception for each

Woman Depending on her needs
 Remember
The total risks of birth
control are much less than
the total risks of a
pregnancy!!
 Contraception as a contemporary issue

⚫ Allows couples to plan for wanted children, establish

relationship, financial stability
⚫ Allows women to pursue professional life with more
freedom
⚫ Can increase women’s health
– Pregnancy itself has health risks, spacing
pregnancies at least 18 months apart results in better
health for both mothers and children
 Contraception as a global issue
⚫ Helps curtail global population growth & spread of HIV
– Most successful way to reduce population
growth worldwide is to expand women’s
educational and economic
opportunities
– Worldwide, women w/more education
have fewer children

⚫ Different cultures and religions have different views about

contraception:
– Islam: spacing, but no sterilization UNLESS patient’s live affected
– Catholic church forbids contraception (other than abstinence and cycle-
based methods
Contraception as a global
issue
Ideal Contraception:
❖ Acceptable –reqireno user motivation so
compliance not problem.
Safe
❖ Accessible
❖ Less side effects
❖ Low failure rate
❖ Non-invasive
❖ Rapid reverssible
❖ Prevention of STD
 Breastfeeding:
Lactation Amenorrhea Method (LAM)
⚫ Mechanism: Suckling causes increased prolactin,
which inhibits estrogen production and ovulation

⚫ 2% typical use failure rate in 1st six mos.

⚫ Candidates:
– Amenorrheic women < 6 mos post-partum who
exclusively breastfeed (90% of nutrition is breast milk)
– Women free of blood-borne infections
– Women not on drugs that could effect baby
 LAM Complications
⚫ Breastfeeding may increase the risk of mastitis

⚫ Return of fertility or ovulation may precede

menses.

⚫ 33-45% ovulate during 1st 3 months.

⚫ Encourage backup form of contraception

Natural Methods:
1.) Calendar Method (Safe period)
- relies upon the fact that there are certain days
during the menstrual cycle when conception can
occur following ovulation, the ovum is viable within
reproductive tract for a maximum of 24 hrs.
- The life spam of sperm is longer 3 days.
- During 28 day menstrual cycle, ovulation occur
around day 14. This means that coitus must be
avoided from 8th to 17th day.
- Failure rate is high so many couples find it difficult
to adher to this method.
 Calendar or Rhythm Method

Low-risk Days

These days may be

8
unsafe if 28-day cycle
varies as much as 8-9
days between shortest
and longest cycles.

Intercourse on these days

may leave live sperm to
fertilize egg.
Egg may still
be present Ovulation
2.) Ovulation method (The billing’s method)
- Ovulation prediction can be enhanced by several
complementary methods including *Basal body
temperature (BBT) rise in progesterone following
ovulates – rise temp. BBT 0.2-0.4°C, until the onset
of menstruation .
* Cervical mucus – several days before ovulation
mucus appearance of raw egg white, clear, slippery
and stretchy (spinnbarkeit). The final day of fertile
mucus is considered to be the day when ovulation is
most likely to occur and abstinence must be
maintained from first day of fertile mucus until 3
days after the peak day. The end of the fertile period
is characterized by appearance of (infertile mucus)
which is scanty and viscous.
 Basal Body Temperature Method
⚫ BBT=body temp in resting state on waking
⚫ Slight drop immediately before ovulation
⚫ After ovulation, release of progesterone causes
slight increase in temperature
 Cervical Mucus Method
no unprotected
intercourse

Early Transitional Highly Fertile

Mucus Mucus Mucus
• Slight amount • Increasing • Profuse
• Thick amounts • Thin
• White • Thinner • Transparent
• Sticky • Cloudy • Stretchy
• Holds its shape • Slightly stretchy
*Failure rate of natural method mucus and
BBT and Calendar method 2.8 %.

3-personal fertility monitors: small devices

able to detect urine concentration of oestrone
and LH indicate start and end of fertile
period.
- Failure rate 6.2-24%.
- Disadvantage – provide no protection from
STD .
Types of Birth Control
Types of Birth Control
Barrier Methods:
Male Condoms
 Barrier Methods:
Male Condoms
⚫ Sheaths of latex, polyurethane, or natural membranes that
may or may not have spermicide.

⚫ Mechanism: Barrier that prevents sperm and infections from

entering vagina.

⚫ Effectiveness: 15% typical use failure rate.

⚫ Candidates:
– Couples in which one partner has an STD/HIV
– Couples starting other types of birth control
– Couples who can’t use hormonal methods

Warner DL, et al. Contraceptive Technology. 2004

 Barrier Method:
Female Condom
⚫ Disposable single use polyurethane sheath placed in
vagina.

⚫ Flexible movable inner ring at closed end used to insert

into vagina.

⚫ Flexible outer ring to cover part of the introitus.

⚫ Mechanism: Prevents passage of sperm and infections

into the vagina.

⚫ Failure rate is high at 21% with typical use.

Hatcher et al. Managing Contraception.2004
 Barrier Method:
Female Condom
⚫ Candidates the same as for male condoms.

⚫ Female condom is reusable only if the partner does

not have an STD.

⚫ Disadvantages:

– Awkward and difficult to place

– Most users do not enjoy using female condom (88% of
women and 91% of men)
– Many couples complain about noise of condom
Female Condom: “Reality”
 Barrier Method:
Cervical Cap
⚫ Thimble- shaped latex rubber device which
has an inner ring that provides suction to
keep cap on the cervix.

⚫ Spermicide is placed inside the cap before

being placed on the cervix to kill sperm.

⚫ 4 sizes: 22, 25, 28, 31 mm.

⚫ Mechanism: barrier that prevents sperm

migration into cervical canal
 Barrier Method:
Cervical Cap
⚫ Advantages:
– May decrease risk of GC, Chl, and PID
– Can be placed 6 hours prior to intercourse
– Can remain in vagina up to 48 hours for multiple
acts of intercourse

⚫ Disadvantages:
– No protection against HIV
– Poor fit especially in parous women
– Failure Rate: As high as 32% in parous women and
16% in nulliparous women
– Patient must leave in place at least 8 hours after
intercourse before removing
Diaphragm
 Barrier Method:
Diaphragm
⚫ Latex rubber dome-shaped device that covers
the cervix

⚫ Mechanism: prevents sperm from entering

cervical canal

⚫ Three types:
⚫ Arcing Spring
⚫ Coil Spring
⚫ Wide Seal
 Barrier Method:
Diaphragm
⚫ Typical use failure rate: 16% in one year

⚫ May reduce risk of GC, Chl, PID

⚫ Risks:
⚫ No protection from HIV
⚫ Difficult to place around cervix
⚫ May fall out in women with pelvic relaxation
⚫ May cause vaginal erosions & infections
⚫ May cause reaction in latex allergic
⚫ Toxic Shock Syndrome
⚫ Urinary Tract Infections
 SPERMICIDE
⚫ Most common is nonoxynol-9

⚫ Available in creams, films, foams, gels,

suppositories, sponges, and tablets

⚫ Best when used with barrier methods

⚫ 29% typical use failure rate when used alone

⚫ Provides no protection against STD’s and HIV

Sponge
Oral Contraceptive Pills
 Combined Oral Contraceptives
(Estrogen & Progestin)

⚫ Mechanism:

– Blocks ovulation

– Thickens cervical mucus

– Thins the endometrial lining

 Gonadotropin releasing
hormone (GnRH)
How hormonal
triggers release of
gonadotropins FSH & LH
contraceptives
work

Estrogen & progesterone in

hormonal contraceptives
inhibit LH, FSH, and GnRH
secretion, preventing ovulatio


Progesterone also:
•thickens cervical mucus to prevent
Passage of sperm into the uterus
•changes uterine lining to inhibit implantation
 Combined contraception pills (COC)
 Estrogen component of most modern COC is ethinyloestradiol
(EE) 20-50 ug.

 Progesterone Component
 Second generation (e.g. norethisterone and levonorgestrill)
 Third generation (e.g. desogestrel and gestodene)

Third generation have higher affinity for progestrone

receptors and lower affinity for the androgen receptor than
secondary generation, i.e. They confer greater efficacy with
few androgenic S.E.
They are also have fewer effect on carbohydrate and lipid
metabolism.
 Combined Oral Contraceptives
(Estrogen & Progestin)
⚫ Non-contraceptive Uses of OCPs

– Dysfunctional uterine bleeding

– Dysmenorrhea

– Mittelschmerz

– Endometriosis prophylaxis

– Acne and hirsutism

– Hormone replacement

– Prevention of menstrual porphyria

– Functional ovarian cysts

 Combined Oral Contraceptives
(Estrogen & Progestin)
Advantages:

– Less endometrial cancer (50% reduction)

– Less ovarian cancer (40% reduction)
– Less benign breast disease
– Fewer ovarian cysts (50% to 80% reduction)
– Fewer uterine fibroids (31% reduction)
– Fewer ectopic pregnancies
– Fewer menstrual problems
--more regular
--less flow
--less dysmenorrhea
--less anemia
– Less salpingitis (pelvic inflammatory disease)
– Less rheumatoid arthritis (60% reduction)
– Increased bone density
– Probably less endometriosis
 Combined Oral Contraceptives
(Estrogen & Progestin)
Disadvantages

▪ Spotting especially in 1st few months

▪ May decrese Libido

▪ Requires daily pill intake

▪ No protection against STD’s and HIV

▪ Possible weight gain

▪ Post-contraception amenorrhea
 Combined Oral Contraceptives
(Estrogen & Progestin)
⚫ Absolute Contraindications:

– Thromboembolic disorder (or history thereof)

– Cerebrovascular accident (or history thereof)
– Coronary artery disease (or history thereof)
– Impaired liver function (current)
– Hepatic adenoma (or history thereof)
– Breast cancer, endometrial cancer, other estrogen-dependant malignancies
– Pregnancy
– Undiagnosed vaginal bleeding
– Tobacco user over age 35
 Combined Oral Contraceptives
(Estrogen & Progestin)
⚫ Relative Contraindications

– Migraine headaches, esp. worsening with pill use

– Hypertension

– Diabetes mellitus

– Elective surgery (needs 1 to 3 month discontinuation)

– Seizure disorder, anticonvulsant use

– Sickle cell disease (SS or sickle C disease (SC)

– Gall bladder disease.

 D.V.T. RISK
⚫ 100,000 healthy women = 5

⚫ 100,000 on 2nd generation pills = 15

⚫ 100,000 on 3rd generation pills = 30

⚫ 100,000 healthy pregnantwomen = 60

⚫ Failure of the Pill:

⚫ If patient forget to take the pill.

⚫ Gastroentroentritis.
⚫ Drugs – Anticonvulsant
– Phenytoin,
– Phenobarbitone
– Antibiotics
 Choosing The Right OCP’s

⚫ Endometriosis: Choose a pill with a strong progestin to create a

pseudo-pregnancy state

⚫ Functional Ovarian Cysts: High dose monophasic pill may be

more effective

⚫ Androgen excess: Choose a pill with high estrogen/progestin

ratio to reduce free testosterone and inhibit 5 reductase activity

⚫ Breastfeeding: Progestin -only pill

Estrogen / Progestin
Patch

• 1 patch weekly for 3 weeks, then one week

off
• Same efficacy & contraindications as OCs
• OK to shower, swim, exercise with patch on
• Failures in trials were in women over 95 kg,
but still rare
• Higher risk of clots? Conflicting studies…
 Transdermal: Ortho Evra
⚫ Advantages:
– Only has to be replaced once per week
– May be taken continuously

⚫ Disadvantages:
– May slip off- provide pt. with an emergency patch
– Patch may be less effective in women who are > 95 kg
Vaginal Contraceptive Ring: NuvaRing
⚫ Combined hormonal contraception consisting of a
5.4 cm diameter flexible ring

⚫ 15 mcg ethinyl estradiol and 120 mcg of

desogestrel

⚫ Mechanism: suppresses ovulation

⚫ Typical use failure rate: 8%

Vaginal Contraceptive Ring: NuvaRing

⚫ Place in vagina and remove after 3 weeks

⚫ Allow withdrawal bleeding and replace new ring

⚫ Steady low release state

⚫ Advantage is patient only has to remember to insert

and remove the ring 1x/ month

⚫ May be placed anywhere in the vagina

Hormonal Contraceptive
“Progesterone only”
 Hormonal Contraceptive
“Progesterone only”
Progestin works in three major ways:
1) it suppresses GnRH release from the hypothalamus,
decreasing LH and FSH release;

2) it prevents the LH surge from the pituitary, which

prevents ovulation; and

3) it thickens cervical mucus, which impedes sperm entry

into the uterus.
 PROGESTRONE ONLY
PILL
⚫ It is called “ Lactation pills” or ‫حبوب الرضاعة‬
⚫ Safest to use in the purpureum : does not
increase DVT risk or cardiovascular
⚫ Does not affect Breast milk production
⚫ Needs daily non stop use.
⚫ Main side effect: spotting and acne
⚫ Fast reversible
PROGESTRONE ONLY
PILL
 Depo Provera
⚫ 150 mg IM every 3 months

⚫ Contraceptive level maintained for 14 weeks

⚫ Failure Rate: 3% typical use failure rate

⚫ Mechanism:

– Thickens cervical mucus

– Blocks the LH surge
– Initiate treatment during the first week of menses
 Depo Provera
⚫ Advantages ⚫ Disadvantages

– Long acting – Irregular bleeding (70% in

first year)
– Estrogen-free
– Breast tenderness
– Safe in breast-feeding
– Weight gain
– Can be used in sickle-cell
disease and seizure disorder – Depression

– Pt. does not have to take daily – Slow return of menses after
stopping use
– Increases milk quality in
nursing mothers – Osteoporosis after long use
 Depo Provera

– IT IS WITHDRAWN FROM THE MARKET

 Other hormonal methods (cont.)
⚫ Contraceptive Implants
– 1.5” rod is inserted under skin of upper arm
– Progestin-only
– Effective for up to 3 years
– Pros: no daily pill; spontaneity
– Cons: no STD protection, weight gain,
– bleeding, mood change, surgical procedure
– 99.95% effectiveness rate
Intrauterine Devices
 Intrauterine Devices (IUDs)
⚫ Small plastic objects inserted into
uterus
⚫ 2 types
– Hormone-releasing (progesterone)
– Copper-releasing progterone
⚫ Have fine plastic threads
attached that hang slightly out of
cervix into vagina for removal
⚫ Very high continuation rate (how many women are still
using it one year after starting) compared w/other methods
 IUD Mechanisms of Action

Levonorgestrel-Releasing IUD Copper-Releasing IUD

(LNG-IUS, Mirena®) (ParaGard® T380A)

– Inhibits fertilization – Inhibits fertilization

– Thickens cervical mucous – Releases copper ions
– Inhibits sperm function (Cu2+) that reduce sperm
motility
– Thins and suppresses the
– May disrupt the normal
endometrium
division of oocytes and the
formation of fertilizable
ova
 Costs, pros, & cons of IUDs
⚫ Costs
– Copper: 150 S.R. (good for up to 10 years)
– Hormone: 380 S.R. (good for up to 5 years)
⚫ Advantages
– Very effective (essentially no “user error”)
– Long-term protection
– No interruption of sexual activity
– Don’t have to remember to use
– Can be used during breast-feeding
⚫ Disadvantages
– No STI protection
– Risk of PID (usually within first 1-2 months following insertion)
– Rare incidence of perforating uterine wall
INSERTION
COMPLICATIONS
 Sterilization
⚫ Essentially permanent, although vasectomies are
sometimes reversible
⚫ Does not affect hormones, desire, sexual functioning
⚫ Female sterilization
– Tubal sterilization: fallopian tubes are severed to block passage of
sperm & eggs
– Transcervical sterilization: tiny coil inserted through cervix into
fallopian tubes
⚫ Coil promotes tissue growth that, after 3 months, blocks fallopian tubes
⚫ Male sterilization (vasectomy)
– Safer, less expensive, fewer complications than female
sterilization
– Cutting and closing vas deferens (ducts that carry sperm)
 Ex. of female sterilization procedure

⚫ Laparoscope: narrow, lighted viewing instrument that is inserted

into abdomen to locate the fallopian tubes
 VASECTOMY
⚫ Male sterilization procedure

⚫ Ligation of Vas Deferens tube

⚫ Faster and easier recovery than a tubal

ligation

⚫ Failure rate = 0.1%, more effective than

female sterilization
 During a vasectomy (“cutting the vas”) a urologist cuts and
ligates (ties off) the ductus deferens. Sperm are still produced
but cannot exit the body. Sperm eventually deteriorate and
are phagocytized. A man is sterile, but because testosterone
is still produced he retains his sex drive and secondary sex
characteristics.
 Emergency Contraception (EC)

⚫ Any method used after unprotected or

inadequately protected sexual intercourse

⚫ Three types of EC :

⚫ High dose progestin only ( Plan B)

⚫ Yuzpe method- 13 different combined oral
contraceptives (Preven)
⚫ Copper IUD ( Paragard)
 Emergency Contraception (EC)
⚫ Mechanism: Prevents fertilization and implantation.

⚫ Counsel patients that this method does not abort a pregnancy that is
already implanted

⚫ Common in women after an assault or rape

⚫ Most women will have a cycle 21 days after completing emergency

contraception

⚫ If patient does not have a cycle in 21 days, it is important to check a

pregnancy test
 Emergency Contraception (EC)
⚫ High dose progestin-only (Plan B):

⚫ 1.5mg Norgestrel at one time or in divided doses.

⚫ Divided Dose: 1st dose within 72-120 hours of

intercourse. 2nd dose 12 hours later.

⚫ One dose: Both tablets within 72-120 hours of

intercourse
 Emergency Contraception (EC)
⚫ Yuzpe Method (Preven)

– 100mcg of ethinyl estradiol and 0.50 mg of

levonorgestrel in each dose.

– 1st dose within 72 hours of intercourse and 2nd dose

12 hours later

– 95% effective within 24 hrs; 75% effective within

72 hrs
 Emergency Contraception (EC)
⚫ Copper IUD
- Place within 5 days of unprotected coitus.
– This is usually given to women who plan to use the
IUD for long term birth control or unsuitable for
hormonal method.
– Interferes with implantation after fertilization.
– 99% effective if inserted within 5 days
 New Directions in Contraception for
men
⚫ The “male pill”: Testosterone & progestin may
lower sperm count
⚫ New forms of reversible vasectomy
⚫ On-demand male contraception via acute
inhibition of soluble adenylyl cyclase,, in mice
⚫ (Soluble adenylyl cyclase (sAC) is essential for sperm motility
and maturation. We show a single dose of a safe, acutely-acting
sAC inhibitor with long residence time renders male mice
temporarily infertile.) trials to start in men
New Directions in Contraception for
women
⚫ Most new developments are improvements on
existing contraception for females
– Variations on methods of delivery, formulation of
hormones
– New designs of IUDs, female condoms
– spermicides with microbicides (to kill microbes that
cause STIs)