2. INTRODUCTIONINTRODUCTION
• According to figures
from the population
Reference Bureau, there
are 8300 million humans on the
planet.
• There are 42 births and 17 deaths
every 10 seconds, a net gain of 25
extra people somewhere on the
globe every 10 seconds.
3. INTRODUCTIONINTRODUCTION
• According to UN figures, out of about
180 million conceptions each year, at
least 75 million are unwanted.
• This results in about 50 million
abortions.
• Around 600 000 women die each year
(one woman/min)- killed by
pregnancies.
• 200 000 would not die if adequate
services/contraception make available
to them
4. CHOOSING
CONTRACEPTIVE METHOD
• Individual general health
• Frequency of sexual relationship
• Consideration for adolescent women
• Number of partners
• Considerations for women who have recently given birth
• Considerations for women near menopause
Religion and Moral belief
5. COUNSELLING
• Mode of action
• Effectiveness
• Side effects
• Benefits
• How to use the method
13. The PillThe Pill
• Oral contraceptives have gone
through many changes through the
years since they were introduced in
the 1960s.
• When taken regularly and according
to the directions, birth control pills are
98% to 99% effective in preventing
pregnancy
14. Combined oral cont racept ive
pills
• “The pill” contains combination of two hormones
- Synthetic oestrogen
- Synthetic progesterone
19. WHO medical eligibity criteriaWHO medical eligibity criteria
for contraception use.for contraception use.
20. Who Should Not Use the PillWho Should Not Use the Pill
1. A history of pulmonary embolism or
genetic disorders that could cause
thrombosis (blood clots).
2. Uncontrolled hypertension
3. A history of stroke or heart attack
4. Severe liver disease
5. Migraine headaches with a
neurological component
21. Who Should Not Use the PillWho Should Not Use the Pill
6. Diabetes with retinopathy or kidney
problems (diabetes alone does not
prevent the use of the pill)
7. Estrogen-dependent cancer of the
breast or endometrium
22. Mode of Action COCPMode of Action COCP
Suppression of ovulationSuppression of ovulation
By prevention of ovarian follicular maturationBy prevention of ovarian follicular maturation
By interrupting the oestrogen-mediated positiveBy interrupting the oestrogen-mediated positive
feedback on the hypothalamic-pituitary axis thusfeedback on the hypothalamic-pituitary axis thus
preventing LH surgepreventing LH surge
Thicken the cervical mucusThicken the cervical mucus
reduce sperm penetrabilityreduce sperm penetrability
Thinning of the endometriumThinning of the endometrium
reducing likelihood of implantationreducing likelihood of implantation
23. When to take the pill?When to take the pill?
In principal: at any time if it is reasonably certain that the woman is not pregnantIn principal: at any time if it is reasonably certain that the woman is not pregnant
24. How to take the pill?How to take the pill?
1 pill is taken every day for 21 days and followed by 71 pill is taken every day for 21 days and followed by 7
days of pill free period, during which the women will havedays of pill free period, during which the women will have
a ‘withdrawal bleed’.a ‘withdrawal bleed’. For YAZ , 24days & 4 days pill freeFor YAZ , 24days & 4 days pill free
period.period.
Timing is not as critical as it is with POPs, but it is a goodTiming is not as critical as it is with POPs, but it is a good
practice to get into habit of taking the pill at a similar timepractice to get into habit of taking the pill at a similar time
every day.every day.
25. Missed pillsMissed pills
PrincipalPrincipal
It takes 7 consecutive pills to ensure thatIt takes 7 consecutive pills to ensure that
ovulation has been suppressedovulation has been suppressed
It is thus vital to avoid lengthening the pill freeIt is thus vital to avoid lengthening the pill free
week to more than 7 daysweek to more than 7 days
26. Missed 1Missed 1stst
weekweek
If pills are missed in the FIRST 7 DAYS ofIf pills are missed in the FIRST 7 DAYS of
pill taking, the ovaries will not have 7pill taking, the ovaries will not have 7
consecutive pills to ensure suppression ofconsecutive pills to ensure suppression of
ovulation following pill-free week THUSovulation following pill-free week THUS
emergency contraception should be givenemergency contraception should be given
if necessary and EXTRA PRECAUTIONSif necessary and EXTRA PRECAUTIONS
used until seven further pills have beenused until seven further pills have been
taken without a breaktaken without a break
27. Missed 2Missed 2ndnd
weekweek
If pills are missed in the SECOND 7 DAYSIf pills are missed in the SECOND 7 DAYS
of the packet then the ovaries will have atof the packet then the ovaries will have at
least 7 pills to ensure suppression ofleast 7 pills to ensure suppression of
ovulationovulation THUS theoreticallyTHUS theoretically emergencyemergency
contraception and extra precautioncontraception and extra precaution
SHOULD NOT BE NEEDED.SHOULD NOT BE NEEDED.
28. Missed 3Missed 3rdrd
weekweek
If pills are missed in the THIRD 7 DAYS of pillIf pills are missed in the THIRD 7 DAYS of pill
taking the next packet of pills should be startedtaking the next packet of pills should be started
WITHOUT having PILL FREE WEEKWITHOUT having PILL FREE WEEK
This is again to ensure that seven consecutiveThis is again to ensure that seven consecutive
days of pill taking is achieved before allowing 7days of pill taking is achieved before allowing 7
days free from the pilldays free from the pill
IN PRACTICE women will find it easier to have 1IN PRACTICE women will find it easier to have 1
set of rules to cover all eventualitiesset of rules to cover all eventualities
30. When to stop?When to stop?
In a fit and healthy womanIn a fit and healthy woman with no contraindications towith no contraindications to
taking the pill, there is no need to stop just because oftaking the pill, there is no need to stop just because of
age.age.
However, with regular bleeds and normal levels ofHowever, with regular bleeds and normal levels of
oestrogen, theoestrogen, the onset of the menopause will be maskedonset of the menopause will be masked..
It is wise toIt is wise to choose the age of 50 to stop the COCchoose the age of 50 to stop the COC pillpill
and use another method of contraceptionand use another method of contraception
Taking COCP would mask common bld markers of theTaking COCP would mask common bld markers of the
menopause such as oestradiol and FSH levels – thismenopause such as oestradiol and FSH levels – this
effect disappears after 6 weekseffect disappears after 6 weeks and levels of theseand levels of these
markers can be relied on.markers can be relied on.
31. AdvantagesAdvantages
High efficacyHigh efficacy
Failure rate (pearl index) 0.1-1/100 woman yearsFailure rate (pearl index) 0.1-1/100 woman years
ReversibleReversible
Prompt return to ovulation with 70% of women ovulating inPrompt return to ovulation with 70% of women ovulating in
the 1the 1stst
cycle and 98% by the 3cycle and 98% by the 3rdrd
cyclecycle
Not related to intercourseNot related to intercourse
Reduction in menstrual blood flowReduction in menstrual blood flow
Reduced the menstrual blood flow by 50%Reduced the menstrual blood flow by 50% especially with YAZespecially with YAZ
32. AdvantagesAdvantages
Less dysmenorhoeaLess dysmenorhoea
Reduce menstrual prostaglandin release thus reducingReduce menstrual prostaglandin release thus reducing
uterine contractility and dysmenorrhoeauterine contractility and dysmenorrhoea
Predictability of mensesPredictability of menses
Treats PMS/PMDD,Treats PMS/PMDD, especially with YAZ.especially with YAZ.
Reduction in benign breast diseaseReduction in benign breast disease
Reduction in functional ovarian cystReduction in functional ovarian cyst
Reduction in PIDReduction in PID
Due to progesterone effect on cervical mucus- increase viscosityDue to progesterone effect on cervical mucus- increase viscosity
impedes ascent of pathogens and may confer protective effect.impedes ascent of pathogens and may confer protective effect.
Lower menstrual flow also reduces bacterial growthLower menstrual flow also reduces bacterial growth
33. AdvantagesAdvantages
Reduction in ectopic pregnancy rateReduction in ectopic pregnancy rate
All forms of contraception reduce the incidence of ectopicAll forms of contraception reduce the incidence of ectopic
pregnancypregnancy
Risk of ectopic pregnancy in COCP users is 0.005 per 1000Risk of ectopic pregnancy in COCP users is 0.005 per 1000
woman years, comparable to that associated with vasectomywoman years, comparable to that associated with vasectomy
and lower than the risk associated with barrier contraception,and lower than the risk associated with barrier contraception,
IUCD or tubal ligationIUCD or tubal ligation
Reduction in ovarian and endometrial cancerReduction in ovarian and endometrial cancer
COCP use for 4 and 8 years associated with 40% and 51% reduction inCOCP use for 4 and 8 years associated with 40% and 51% reduction in
risk of ovarian cancer respectivelyrisk of ovarian cancer respectively
COCP use for 4 and 8 years associated with 54% and 66% reduction inCOCP use for 4 and 8 years associated with 54% and 66% reduction in
risk of endometrial cancer respectivelyrisk of endometrial cancer respectively
34. DisadvantagesDisadvantages
Cardiovascular effectCardiovascular effect
VTEVTE
Myocardial infarctionMyocardial infarction
Cerebrovascular accidentsCerebrovascular accidents
Raised blood pressureRaised blood pressure
Breast cancerBreast cancer
Cervical cancerCervical cancer
Compared with never users of oral contraceptives, the relative risksCompared with never users of oral contraceptives, the relative risks
of cervical cancer increased with increasing duration of useof cervical cancer increased with increasing duration of use
Liver adenoma or carcinomaLiver adenoma or carcinoma
CholestasisCholestasis
GallstonesGallstones
38. ORTHO EVRAORTHO EVRA
ContainsContains 6mg norelgestromin6mg norelgestromin
and 0.75mg ethinyl oestradioland 0.75mg ethinyl oestradiol
20 cm squared trans-dermal system –apply at upper20 cm squared trans-dermal system –apply at upper
outer arm, abdomen, buttock and backouter arm, abdomen, buttock and back
The patch isThe patch is changed every 7 dayschanged every 7 days for 3 weeks with afor 3 weeks with a
drug-free 7 day intervaldrug-free 7 day interval
Patient compliance is significantly higher with the
contraceptive patch compared to oral contraceptive pills
But expensive.
Pearl index = 0.88. In comparativePearl index = 0.88. In comparative trials, efficacy better, efficacy better
than COCPthan COCP
39. Transdermal ContraceptiveTransdermal Contraceptive
System: DescriptionSystem: Description
• 3-patch system
– Apply 1 patch each week for 3 weeks
– Apply each patch the same day of the
week
• 1 week is patch-free
Week 1 Week 2 Week 3 Week 4
Patch #1 Patch #2 Patch #3
28-day cycle
Patch-free
Week 5
Start next cycle
28-day cycle
Abrams LS, et al. J Clin Pharmacol. 2001;41:1232-1237, 1301-1309; Abrams LS, et al.
Contraception. 2001;64:287-294; Creasy GW, et al. Semin Reprod Med. 2001;19:373-380; Audet
MC, et al. JAMA. 2001;285:2347-2354; Smallwood GH, et al. Obstet Gynecol. 2001;98:799-805.
40. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
ApplicationApplication
• Size: 20 cm2
• Composed of 3 layers:
– a release liner removed at
the moment of
application
– a medicated adhesive layer
– An outer protective polyester
layer
• Applied to the buttocks,
upper outer arm, lower
abdomen, or the upper
torso (excluding the
breast)
Keder LM. J Pediatr Adolesc Gynecol. 2002;15:179-181.
41. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
AdvantagesAdvantages
• Weekly application
encourages compliance
• Easy verification of
presence reassures user
of continued protection
• Does not require vaginal
insertion
• Contraceptive effects
are rapidly reversible
• Excellent cycle control
after 3 months
42. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
DisadvantagesDisadvantages
• Application site reactions
• Not as effective in women
weighing >198 pounds
• Side effects are similar to
oral contraceptives except
for:
- higher rates of breast pain
during first 2 months
- higher rates of dysmenorrhea
• May be difficult to conceal
• No protection against HIV or
other sexually transmitted
infectionsZieman M, et al. Fertil Steril. 2002;77(Suppl 2):S13-S18.
43. Transdermal Contraceptive Patch: PooledTransdermal Contraceptive Patch: Pooled
Analysis of EfficacyAnalysis of Efficacy
Through 13 CyclesThrough 13 Cycles
22,160
Cycles
Number of
Pregnancies
Probability of
Pregnancy*
Method
Failure
12 0.8%
User
Failure
3 0.6%
*Kaplan-Meier estimates of the cumulative probabilities of
pregnancy.
Zieman M, et al. Fertil Steril. 2002;77(Suppl 2):S13-S18; Smallwood GH, et al.
Obstet Gynecol. 2001;98(Pt 1):799-805; Audet MC, et al. JAMA. 2001;285:2347-
2354; Hedon B, et al. Int J Gynaecol Obstet. 2000:70(suppl 1):78.
44. Efficacy of the Contraceptive PatchEfficacy of the Contraceptive Patch
Versus an Oral ContraceptiveVersus an Oral Contraceptive
Cycle
s
No. of
Pregnancies
Probability of
Pregnancy Pearl Index
Metho
d
failure
User
failure
Metho
d
failure
Overal
l
Method
*
Overall
†
Patch
(n=811
)
5,240 4 1 1.1 1.3 0.99 1.24‡
OC
(n=605
)
4,167 4 3 1.3 1.8 1.25 2.18‡
Patch = Ortho Evra®
transdermal patch; OC = Triphasil®
oral contraceptive
*
Failure when taken as directed
†
User failure plus method failure
‡
The difference in efficacy was not statistically significant
Audet MC, et al. JAMA. 2001;285:2347-2354.
45. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
Most Common Adverse EventsMost Common Adverse Events
Audet MC, et al. JAMA. 2001;285:2347-2354.
Adverse Event
Number of Patients (%)
Ortho Evra®
Patch
(n=812)
Oral
Contraceptiv
e
(n=605)
P
Value
Headache 178 (21.9) 134 (22.1) 0.95
Nausea 166 (20.4) 111 (18.3) 0.34
Application site reaction 164 (20.2) – –
Breast discomfort* 152 (18.7) 35 (5.8) <0.001
Upper respiratory infection 108 (13.3) 108 (17.9) 0.02
Dysmenorrhea 108 (13.3) 58 (9.6) 0.04
Abdominal pain 66 (8.1) 51 (8.4) .85
*
Reported only during the first 2 study cycles.
46. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
Patient Counseling on Usage and DisposalPatient Counseling on Usage and Disposal
• Application:
– Use a new location for each patch
– Apply to clean, dry skin
– Apply where it won’t be rubbed by clothing: on buttocks,
abdomen, upper outer arm, upper torso
– Do not use on irritated or abraded skin
– Do not use on the breasts
– Avoid oils, creams, or cosmetics until after patch placement
– Bathe and swim as usual
• Anticipate more breast discomfort during the first 2
months
• Store at room temperature
• Do not cut, alter or damage the patch as if may alter
contraceptive efficacy
• Do not flush a used patch into the water system; fold
the used patch in half and place in the trash
47. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
Patient Counseling on Basic InstructionsPatient Counseling on Basic Instructions
• If switching from an oral contraceptive, apply the
patch as soon as withdrawal bleeding begins (Day 1
Start)
- Sunday Start: use backup protection for 7 days unless
Sunday is the first day of the menstrual cycle
• Wear each patch for 7 days; subsequent patch
changes are made on the same day of the week
• No more than 7 days should lapse between the
application of the last patch of the prior 21-day cycle
and the first patch of the next 21-day cycle
• For partial or full detachment, make sure the
exposed undersurface of the patch is clean and
adherent; press it into place for 10 seconds; if the
patch does not adhere completely, remove it and
replace it with another patch
48. 28-Day Cycle (Days 1-28)
Patch #1
Days 1-7
Patch #2
Days 8-15
Patch #3
Days 16-21
No Patch
Next 28-Day Cycle (Days 29-56)
This patch was not applied:
• Apply a new patch immediately; this is the new “patch change day”
• Use backup protection for 7 days
• Consider emergency contraception
Patch application is 1 to 2 days late:
• Apply new patch immediately; Make this the new “patch change day”
• No backup protection is required
Patch application is >2 days late:
• Immediately start new 21-day application cycle
•Use backup protection for 7 days
•Consider emergency contraception
Patch #1
This patch was not removed:
• Remove immediately
• Start cycle on day 29
Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
Managing Missed or Late ApplicationsManaging Missed or Late Applications
49. Contraception During Perimenopause:Contraception During Perimenopause:
Transdermal PatchTransdermal Patch
Available
methods
(Failure
rates)*
• Ethinyl
estradiol/norelgestromin
patch (8%)
Prevents
unintended
pregnancy
Yes
Minimizes
hormonal
fluctuations
Yes
Provides
additional
health benefits
• Bone protection
• Cycle control
Grimes DA, Wallach M, eds. Modern Contraception: Updates from The
Contraception Report. 2007; Hatcher RA, Nelson AL. In: Contraceptive
Technology. 2004:391-460.
50. Transdermal Contraceptive Patch:Transdermal Contraceptive Patch:
Risk for Venous ThromboembolicRisk for Venous Thromboembolic
Events*Events*
Jick SS, et al. Contraception. 2006;73:223-228;
Cole JA, et al. Obstet Gynecol. 2007;109:339-346.
Relevant
Studies
Odds Ratio
(95% Confidence
Interval)
Jick SS, et al.,
2006
0.9 (0.5–1.6)
Cole JA, et al.,
2007
2.4 (1.1–5.5)
*Women should be counseled that all combined
contraceptive products increase the risk of venous
thromboembolic events; use of these products should
be discontinued if a patient becomes immobilized.
52. NUVANUVA ringring
• It is made of latex-free plastics.
• Diameter : 54 mm
• CONTAINS ethinyl estradiol 15 ug
and etonorgestrel 120 ug.
• The ring is worn for 21 days and
removed for 7 days to allow
withdrawal bleedings.
• Same risks and benefits as COC but
is more expensive.
• Cycle control is better &
breakthrough bleeding is less
common.
• Efficacy is 99.4%.
• If remain inserted >4wks backup
contraception untill new ring has
been in place for 7 days.
56. Progestogen-only PillsProgestogen-only Pills
Suitable for women with VTE, migraine, olderSuitable for women with VTE, migraine, older
women who smoke, women with hypertension,women who smoke, women with hypertension,
valvular heart disease and diabetes mellitus –valvular heart disease and diabetes mellitus –
avoids oestrogenic S/E of COCPavoids oestrogenic S/E of COCP
ContraindicationsContraindications
PregnancyPregnancy
Undiagnosed vaginal bleedingUndiagnosed vaginal bleeding
Severe arterial diseaseSevere arterial disease
Liver adenomaLiver adenoma
57. AdvantagesAdvantages
Failure rate 0.3-3/100 women yearsFailure rate 0.3-3/100 women years
Effective when used correctlyEffective when used correctly
well toleratedwell tolerated
No artificial oestrogen component thus all of the s/eNo artificial oestrogen component thus all of the s/e
related to oestrogen e.g. risk of circulatory disease arerelated to oestrogen e.g. risk of circulatory disease are
potentially absentpotentially absent
Readily reversible method of contraceptionReadily reversible method of contraception
Efficacy increases with age and may be reduced ifEfficacy increases with age and may be reduced if
weight > 70kgweight > 70kg
Do not affect the raised FSH and oestradiol levelsDo not affect the raised FSH and oestradiol levels
associated with menopause thus reduce the problems ofassociated with menopause thus reduce the problems of
diagnosing the menopause on hormonal contraceptiondiagnosing the menopause on hormonal contraception
58. DisadvantagesDisadvantages
Strict adherence to the rules of pill takingStrict adherence to the rules of pill taking
is essentialis essential
Pattern of bleeding is unpredictablePattern of bleeding is unpredictable
Associated with increased incidence ofAssociated with increased incidence of
ovarian follicular cysts and increased riskovarian follicular cysts and increased risk
of ectopic pregnancy (compared toof ectopic pregnancy (compared to
COCP)COCP)
59. Mode of actionMode of action
Main effect : Thicken cervical mucus thusMain effect : Thicken cervical mucus thus
decreased sperm penetrability of cervixdecreased sperm penetrability of cervix
Reduce receptivity of endometrium toReduce receptivity of endometrium to
implantationimplantation
Reduction in ovulationReduction in ovulation
Suppress ovulation inSuppress ovulation in ~~40%, this is unpredictable and varies40%, this is unpredictable and varies
between cycles resulting in irregular menstruationbetween cycles resulting in irregular menstruation
10-15% of women have complete inhibition of ovarian activity10-15% of women have complete inhibition of ovarian activity
and are amenorrhoeicand are amenorrhoeic
50%have regular ovulatory cycles with normal luteal phase50%have regular ovulatory cycles with normal luteal phase
and a normal menstrual cycleand a normal menstrual cycle
Reduce fallopion tube motilityReduce fallopion tube motility
60. How to take?How to take?
One tablet daily taken on day 1 of cycle and takenOne tablet daily taken on day 1 of cycle and taken
continuously without a breakcontinuously without a break
Should be taken at the same time every day andShould be taken at the same time every day and
within 3 hrs at the mostwithin 3 hrs at the most
If pill missed for more than 3 hrs, additionalIf pill missed for more than 3 hrs, additional
precautions needed for following 2 days –precautions needed for following 2 days – An estimatedAn estimated
48hrs of POP use was deemed necessary to achieve the contraceptive effects on48hrs of POP use was deemed necessary to achieve the contraceptive effects on
cervical mucuscervical mucus
Maximal effect on cervical mucus is at 4 hrs after pillMaximal effect on cervical mucus is at 4 hrs after pill
takingtaking
The only antibiotics that would reduce the efficacy ofThe only antibiotics that would reduce the efficacy of
the POP are the enzyme inducer such as rifampicin orthe POP are the enzyme inducer such as rifampicin or
griseofulvingriseofulvin
61. When to take the pill?When to take the pill?
POP can be started at any time ifPOP can be started at any time if
pregnancy can be excludedpregnancy can be excluded
First day or two of menses, if started laterFirst day or two of menses, if started later
than this – extra precautions needed forthan this – extra precautions needed for
following 7 daysfollowing 7 days
Can be started immediately following aCan be started immediately following a
miscarriage or termination of pregnancymiscarriage or termination of pregnancy
When changing from COCs, an immediateWhen changing from COCs, an immediate
switch is recommendedswitch is recommended
62. CerrazetteCerrazette®®
Released in 2003Released in 2003
Contain 3Contain 3rdrd
generation of progestogen –generation of progestogen –
desogestrel 75mcgdesogestrel 75mcg
Evidence show that it inhibits ovulation in 97% ofEvidence show that it inhibits ovulation in 97% of
cyclescycles
Window period of 12 hoursWindow period of 12 hours instead of 3 hoursinstead of 3 hours
Taken every day with no breakTaken every day with no break
Useful for younger women who cannot or do notUseful for younger women who cannot or do not
wish to take oestrogen containing products orwish to take oestrogen containing products or
women who cannot tolerate other POPs.women who cannot tolerate other POPs.
64. INJECTABLESINJECTABLES
PreparationsPreparations
• DMPA : Depo-provera (depotDMPA : Depo-provera (depot
medroxyprogesterone acetate)medroxyprogesterone acetate)
• NET-EN : norethisterone enantateNET-EN : norethisterone enantate
Main effect : inhibition of ovulationMain effect : inhibition of ovulation
Also has effect on endometrial and cervical mucusAlso has effect on endometrial and cervical mucus
65. Depo-proveraDepo-provera®®
Depo-Depo-
medroxyprogesteronemedroxyprogesterone
acetate 150mgacetate 150mg
Deep im injectionDeep im injection
Every 3 months +/- 2Every 3 months +/- 2
weeksweeks
Failure rate 0.25-0.5/100Failure rate 0.25-0.5/100
woman yearswoman years
Use of broad spectrumUse of broad spectrum
antibiotics do notantibiotics do not
compromised efficacycompromised efficacy
since the route does notsince the route does not
depend on absorptiondepend on absorption
from the gutfrom the gut
66. BenefitsBenefits
Suitable for womenSuitable for women
who forget to take pills, particularly travellers, due to frequent changeswho forget to take pills, particularly travellers, due to frequent changes
in time zones, missed pills are likely or where suboptimal compliance isin time zones, missed pills are likely or where suboptimal compliance is
expectedexpected
Who wish for a secret or ‘private’ methodWho wish for a secret or ‘private’ method
In whom oestrogen is contraindicated:In whom oestrogen is contraindicated: mild to moderate hypertension,diabetesmild to moderate hypertension,diabetes
mellitus in the absence of vascular disease, age >35yo & smoking)mellitus in the absence of vascular disease, age >35yo & smoking)
Associated with reduction in sickling crises in sufferers ofAssociated with reduction in sickling crises in sufferers of
sickle cell disease and reduced frequency of seizures insickle cell disease and reduced frequency of seizures in
epileptic women having cyclical attacksepileptic women having cyclical attacks
Does not have any effect on the risk of ovarian andDoes not have any effect on the risk of ovarian and
endometrial cancerendometrial cancer
Little or no association with stroke, MI or VTE .Little or no association with stroke, MI or VTE .
67. Side effects & RisksSide effects & Risks
Menstrual disturbances are likely with irregular frequent vaginalMenstrual disturbances are likely with irregular frequent vaginal
bleedingbleeding
Amenorrhoea becomes more likely with repeated dosesAmenorrhoea becomes more likely with repeated doses
• 30% after 130% after 1stst
dosedose
• 55% after 455% after 4thth
dosedose
Weight gainWeight gain
3-19% of users may develop headaches, dizziness, breast3-19% of users may develop headaches, dizziness, breast
tenderness and mood changestenderness and mood changes
Associated with delay in return to normal fertilityAssociated with delay in return to normal fertility
On average following a final injection of DMPA, ovulation returnsOn average following a final injection of DMPA, ovulation returns
after 4-5 months, may be as long as 24 monthsafter 4-5 months, may be as long as 24 months
78% had conceived by 12 months and over 92% had conceived78% had conceived by 12 months and over 92% had conceived
by 24 months following discontinuationby 24 months following discontinuation
Thought to be due to slow metabolism of the drug from theThought to be due to slow metabolism of the drug from the
microcrystalline deposits in muscle tissuemicrocrystalline deposits in muscle tissue
68. Depo-provera and osteoporosisDepo-provera and osteoporosis
There is evidence that depo-provera causes a significantThere is evidence that depo-provera causes a significant
reduction in bone mineral density. This effect may bereduction in bone mineral density. This effect may be
more important in adolescents. This reduction appears tomore important in adolescents. This reduction appears to
be partly reversible after discontinuation and resumptionbe partly reversible after discontinuation and resumption
of ovarian activityof ovarian activity
In adolescentsIn adolescents, it should only be used after other, it should only be used after other
methods have been considered and found to bemethods have been considered and found to be
unsuitable or unacceptableunsuitable or unacceptable
In all women, careful re-evaluation of risks and benefitsIn all women, careful re-evaluation of risks and benefits
of treatment should be undertaken in those who wish toof treatment should be undertaken in those who wish to
continue use forcontinue use for longer than 2 yearslonger than 2 years
69. Depo-subQ provera 104Depo-subQ provera 104
A new micronised,A new micronised,
subcutaneous formulationsubcutaneous formulation
of Depo-proveraof Depo-provera® 104mg® 104mg
Every 12 weeksEvery 12 weeks
Fewer side effects suchFewer side effects such
as weight gainas weight gain
The efficacy and delay inThe efficacy and delay in
return of fertility is similarreturn of fertility is similar
with im depo-provera®with im depo-provera®
Can be self administeredCan be self administered
70. NoristeratNoristerat®®
200mg norethindrone enanthate200mg norethindrone enanthate
Administered every 8 weeks +/- 2 weeksAdministered every 8 weeks +/- 2 weeks
Less effect on bleeding patternLess effect on bleeding pattern
Pearl index 0.4-2.0/100 woman yearsPearl index 0.4-2.0/100 woman years
73. ImplanonImplanon
68mg68mg etonorgestreletonorgestrel – active metabolite of desogestrel– active metabolite of desogestrel
A single 40 mm rod, just 2 mm in diameter.A single 40 mm rod, just 2 mm in diameter.
Initial release rate of 60-70mcg/day and falls gradually toInitial release rate of 60-70mcg/day and falls gradually to
around 25-30mcg at the end of 3 yearsaround 25-30mcg at the end of 3 years
Inserted subdermally in the groove between biceps andInserted subdermally in the groove between biceps and
triceps in the non-dominant hand about 8-10cm from thetriceps in the non-dominant hand about 8-10cm from the
medial epicondylemedial epicondyle
Can be administered up to day 5 of menses without theCan be administered up to day 5 of menses without the
need for additional contraceptionneed for additional contraception
License for 3 years – efficacy may be lower during the 3License for 3 years – efficacy may be lower during the 3rdrd
year in overweight womenyear in overweight women
Inhibit ovulation by prevention of LH surge, also affectInhibit ovulation by prevention of LH surge, also affect
cervical mucus thickening and endometriumcervical mucus thickening and endometrium
74. Implanon- timing of insertionImplanon- timing of insertion
Day 1 to day 5 of menses. If later than dayDay 1 to day 5 of menses. If later than day
2, recommend additional contraception till2, recommend additional contraception till
day 7. If after day 7, must make sureday 7. If after day 7, must make sure
abstinence.abstinence.
Immediate after 1Immediate after 1stst
trimester abortiontrimester abortion
Day 21 after 2Day 21 after 2ndnd
trimester abortion ortrimester abortion or
deliverydelivery
During breast feedingDuring breast feeding
75. Implanon- advantages &Implanon- advantages &
benefitsbenefits
Feature of ‘forgetability’ / better complianceFeature of ‘forgetability’ / better compliance
Long action plus high continuation ratesLong action plus high continuation rates
Efficacy not being affected by broad-spectrumEfficacy not being affected by broad-spectrum
antibioticsantibiotics
Oestrogen free- usable in past VTE, excellentOestrogen free- usable in past VTE, excellent
choice for many diabeticschoice for many diabetics
Unchanged blood pressureUnchanged blood pressure
Can use in past ectopicsCan use in past ectopics
Rapidly reversible- after removal 44/47 womenRapidly reversible- after removal 44/47 women
will ovulate within 3 weekswill ovulate within 3 weeks
Failure rate fewer than 0.1/100 woman yearsFailure rate fewer than 0.1/100 woman years
76. Implanon- problems &Implanon- problems &
disadvantagesdisadvantages
Menstrual disturbancesMenstrual disturbances
Improve over 3-5 monthsImprove over 3-5 months
NSAIDs and low dose COCs are generally effectiveNSAIDs and low dose COCs are generally effective
treatment strategies for implanon related bleedingtreatment strategies for implanon related bleeding
Minor general side effects – acne, headache,Minor general side effects – acne, headache,
abdominal pain, breast pain, dizziness, moodabdominal pain, breast pain, dizziness, mood
changes, reduced libido and hair losschanges, reduced libido and hair loss
Body weight – slight increaseBody weight – slight increase
Possible hypo-oestrogenismPossible hypo-oestrogenism
Local adverse effects – discomfort, expulsion,Local adverse effects – discomfort, expulsion,
migration and scarringmigration and scarring
77. Implanon - contraindicationsImplanon - contraindications
Absolute include progestogen dependantAbsolute include progestogen dependant
tumour, current severe hepatic disease,tumour, current severe hepatic disease,
pregnancy, undiagnosed vaginal bleeding,pregnancy, undiagnosed vaginal bleeding,
severe hypersensitivity and acutesevere hypersensitivity and acute
porphyriaporphyria
Relative include previous ectopicRelative include previous ectopic
pregnancies and liver cirrhosispregnancies and liver cirrhosis
78. Levonorgestrel implantLevonorgestrel implant
Jadelle : 2 rods effective for 5 yearsJadelle : 2 rods effective for 5 years
Norplant :Norplant :
6 capsules labelled for 5 years usage6 capsules labelled for 5 years usage
Released a low dose levonorgestrel at rate ofReleased a low dose levonorgestrel at rate of
30-35mcg/24h after 18 months30-35mcg/24h after 18 months
Failure rate 0.2-1/100 women yearsFailure rate 0.2-1/100 women years
Large studies have found that it is effective forLarge studies have found that it is effective for
7 years (in women <70kg)7 years (in women <70kg)
No more available in UK marketNo more available in UK market
81. LNG IUD : MIRENALNG IUD : MIRENA
Long-acting, rapidlyLong-acting, rapidly
reversiblereversible
52mg levonorgestrel52mg levonorgestrel
released at the rate ofreleased at the rate of
20mcg/ day20mcg/ day
Frame is rendered radio-Frame is rendered radio-
opaque by impregnationopaque by impregnation
with barium sulphatewith barium sulphate
Width is 4.8mmWidth is 4.8mm
Licensed forLicensed for
contraception for 5 yearscontraception for 5 years
82. LNG IUD : MIRENALNG IUD : MIRENA
The contraceptive effect is achieved byThe contraceptive effect is achieved by
profound endometrial glandular and stromal atrophy,profound endometrial glandular and stromal atrophy,
a decidualisation effect and a foreign body effect ina decidualisation effect and a foreign body effect in
the uterus rendering the endometrium unresponsivethe uterus rendering the endometrium unresponsive
to oestrogento oestrogen
Changes in the cervical mucus which prevent ascentChanges in the cervical mucus which prevent ascent
of spermatozoaof spermatozoa
After removal, endometrial morphology returnsAfter removal, endometrial morphology returns
to normal with menstruation within 30 daysto normal with menstruation within 30 days
Failure rate of 0.09/100 women yearsFailure rate of 0.09/100 women years
83. When to use?When to use?
May be fitted up to 7 day of menstrual cycleMay be fitted up to 7 day of menstrual cycle
without need of additional contraceptionwithout need of additional contraception
Or at any time in the menstrual cycle with barrierOr at any time in the menstrual cycle with barrier
contraceptives for the next 7 days, if it iscontraceptives for the next 7 days, if it is
reasonably certain that the woman is notreasonably certain that the woman is not
pregnantpregnant
It may be fitted at the time of 1It may be fitted at the time of 1stst
trimester surgicaltrimester surgical
abortionabortion
It is preferable to wait 6 weeks later followingIt is preferable to wait 6 weeks later following
late 2late 2ndnd
trimester abortiontrimester abortion
84. Benefits including non-Benefits including non-
contraceptioncontraception
Return to fertility is rapidReturn to fertility is rapid
Management of menorrhagiaManagement of menorrhagia
Reduction in menstrual blood loss of up to 97% afterReduction in menstrual blood loss of up to 97% after
12 months of use with an increase in serum ferritin12 months of use with an increase in serum ferritin
and Hb concentration.and Hb concentration.
DysmenorrhoeaDysmenorrhoea
Low rate of ectopic pregnancyLow rate of ectopic pregnancy
Management of endometrial hyperplasiaManagement of endometrial hyperplasia
Protection against STD- thickening of cervical mucus,Protection against STD- thickening of cervical mucus,
inactivation of the endometrium and reduced bleedinginactivation of the endometrium and reduced bleeding
Cost effectiveness – compare to cost of hysterectomy/Cost effectiveness – compare to cost of hysterectomy/
medical treatment for menorrhagiamedical treatment for menorrhagia
Progesteron arm of HRT in perimenopausal women.Progesteron arm of HRT in perimenopausal women.
85. Side effects/ complicationsSide effects/ complications
Difficulties might be encounter with insertion especially inDifficulties might be encounter with insertion especially in
nulliparous womannulliparous woman
Irregular bleeding – takes 3 months for endometrialIrregular bleeding – takes 3 months for endometrial
atrophyatrophy
Increased incidence of functional ovarian cystsIncreased incidence of functional ovarian cysts
compared to copper IUD userscompared to copper IUD users
AmenorrhoeaAmenorrhoea
unless appropriately counselled, some women may regard thisunless appropriately counselled, some women may regard this
as abnormalas abnormal
Occurs in 20% of womenOccurs in 20% of women
Prosgestogenic side effects – oedema/ headache/ breastProsgestogenic side effects – oedema/ headache/ breast
tenderness/ acne – subside after a few monthstenderness/ acne – subside after a few months
Expulsion – commonly occurs during first monthExpulsion – commonly occurs during first month
following insertionfollowing insertion
86. COPPER IUCDCOPPER IUCD
11stst
generationgeneration
Copper sevenCopper seven
Copper T 200Copper T 200
22ndnd
generationgeneration
Multiload 250Multiload 250
Nova TNova T
33rdrd
generationgeneration
Copper T380Copper T380
Multiload 375Multiload 375
87. Cu T 380Cu T 380
Licensed for 8 years in the UKLicensed for 8 years in the UK
First choice of IUCDFirst choice of IUCD
Low failure rateLow failure rate
1.4-2.2/100 women over 5 years1.4-2.2/100 women over 5 years
Low expulsion rateLow expulsion rate
~8/100 women over 5 years~8/100 women over 5 years
88. GyneFIX IUCDGyneFIX IUCD
Licensed for 5 yearsLicensed for 5 years
Frameless deviceFrameless device with 6 copper beadswith 6 copper beads
wound around a monofilamentwound around a monofilament
polypropylene threadpolypropylene thread
Should only be inserted by those whoShould only be inserted by those who
have received appropriate traininghave received appropriate training
Has similar efficacy to Cu T 380 but withHas similar efficacy to Cu T 380 but with
significantly lower expulsion ratesignificantly lower expulsion rate
3.0/100 women at 3 years3.0/100 women at 3 years vsvs 7.38/100 women7.38/100 women
89.
90. Copper IUDCopper IUD
Efficacy is dependent on the surface areaEfficacy is dependent on the surface area
of copperof copper
IUDs fitted after the 40IUDs fitted after the 40thth
birthday need notbirthday need not
to be changed, since fertility declinesto be changed, since fertility declines
rapidly at this age and should be removedrapidly at this age and should be removed
1 year after the menopause1 year after the menopause
91. Complications of Copper IUD useComplications of Copper IUD use
ExpulsionExpulsion
Most occur in the first year, especially in the first 3 monthsMost occur in the first year, especially in the first 3 months
Increased risk of expulsion in woman withIncreased risk of expulsion in woman with
• heavy periodsheavy periods
• Insertion within 6 weeks post-partumInsertion within 6 weeks post-partum
• Previous expulsionPrevious expulsion
• Inexperienced operatorInexperienced operator
PerforationPerforation
Risk 1.2/1000 insertionsRisk 1.2/1000 insertions
Pelvic infectionPelvic infection
6 fold increase in risk of developing PID in the first 20 days following insertion compared6 fold increase in risk of developing PID in the first 20 days following insertion compared
with any other timewith any other time
Thereafter the risk of infection remains constant at 1.4/1000 womenThereafter the risk of infection remains constant at 1.4/1000 women
Increased menstrual lossIncreased menstrual loss
Abdominal pain/ dysmenorrhoeaAbdominal pain/ dysmenorrhoea
PregnancyPregnancy
Remove device gently if possible as soon as pregnancy is diagnosed : reduces the risk ofRemove device gently if possible as soon as pregnancy is diagnosed : reduces the risk of
spontaneous miscarriages by 50%spontaneous miscarriages by 50%
Exclude ectopic pregnancy ( risk 1:25 with IUCD)Exclude ectopic pregnancy ( risk 1:25 with IUCD)
92. WHO Medical Eligibility Criteria for IUD Use inWHO Medical Eligibility Criteria for IUD Use in
Women with Certain Medical ConditionsWomen with Certain Medical Conditions
Medical Conditions
TCu-380A
WHO Risk
Category*
LNG-IUS
WHO Risk
Category*
Hypertension (controlled) 1 1
Multiple cardiovascular risk factors 1 2
History of DVT or pulmonary embolism 1 2
Stroke 1 2
Severe valvular heart disease
(complicated)
2 2
HIV infection 2 2
AIDS (clinically well on antiretroviral
therapy)
2 2
WHO. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. 2004. Available at:
http://www.who.int/reproductive-health/publications/mec/iuds.html.
AIDS = acquired immunodeficiency syndrome; DVT = deep vein thrombosis; HIV = human immunodeficiency
virus; IUD = intrauterine device; LNG-IUS = levonorgestrel-releasing IUD; TCu-380A = copper-releasing IUD;
WHO = World Health Organization
*Category 1= there are no restrictions for use of the contraceptive method; Category 2 = the benefits of
using the contraceptive method generally outweigh the theoretical or proven risk
94. 1. Yuzpe regime1. Yuzpe regime
EE 100mcg and LNG 500mcgEE 100mcg and LNG 500mcg
Given two tablets BD 12 hours apartGiven two tablets BD 12 hours apart
GivenGiven within 72 hourswithin 72 hours of unprotected intercourseof unprotected intercourse
Is likely to preventIs likely to prevent 6 out of 8 pregnancies6 out of 8 pregnancies
95. 2. Progesterone only2. Progesterone only
TWO regimesTWO regimes
1. Single dose 1.5mg1. Single dose 1.5mg
levonorgestrellevonorgestrelEscapelleEscapelle
2. Two doses of 0.75mg2. Two doses of 0.75mg
levonorgestrel 12 hours apartlevonorgestrel 12 hours apart
LevonelleLevonelle
Is likely to preventIs likely to prevent 7 out of7 out of
8 pregnancies8 pregnancies
96. 3. Progesterone receptor3. Progesterone receptor
ModulatorModulator
Ulipristal 30mgUlipristal 30mg Marketed asMarketed as EllaOneEllaOne
It is used up to 120 hours following
unprotected intercourse.
S/E – Vomiting
Not recommended to use >one time per cycle
If breast feeding avoid BF for next 36hrs.
97. 4. Copper IUCD4. Copper IUCD
spermicidal and blastocidal action of copper and thespermicidal and blastocidal action of copper and the
prevention of implantationprevention of implantation
Up to 5 days after the first act of unprotected coitusUp to 5 days after the first act of unprotected coitus
Can be removed when menses occurCan be removed when menses occur
Failure rate <1%Failure rate <1%
Main primary complicationsMain primary complications
Uterine cramps/ bleedingUterine cramps/ bleeding
Risk of infectionRisk of infection
98. 5. Mifepristone ( RU486)5. Mifepristone ( RU486)
Not licensedNot licensed for use as emergency contraceptionfor use as emergency contraception
progesterone antagonistprogesterone antagonist
Single dose of 600mg within 72 h of unprotectedSingle dose of 600mg within 72 h of unprotected
sexual intercourse is highly effective and nosexual intercourse is highly effective and no
pregnancies have been reported in randomisedpregnancies have been reported in randomised
trialstrials
Delay in subsequent menses is the main unwantedDelay in subsequent menses is the main unwanted
side effect and seems to be dose related.side effect and seems to be dose related.
102. VasectomyVasectomy
Men should be advised to use contraception untilMen should be advised to use contraception until
azoospermia is confirmedazoospermia is confirmed
1.1. Testing should be done after 8 weeks of vasectomyTesting should be done after 8 weeks of vasectomy
2.2. 2 samples not less than 4 weeks apart should be clear of2 samples not less than 4 weeks apart should be clear of
spermsperm
3.3. International Parenthood Federation suggested at least 20International Parenthood Federation suggested at least 20
ejaculations are required to clear sperm before otherejaculations are required to clear sperm before other
contraceptives methods should be discontinuedcontraceptives methods should be discontinued
Failure rates of 1:2000 in comparison to 1:200 in BTLFailure rates of 1:2000 in comparison to 1:200 in BTL
Not associated with testicular cancer or heart diseaseNot associated with testicular cancer or heart disease
Nearly 75% of men who undergo vasectomy will developNearly 75% of men who undergo vasectomy will develop
antisperm antibodiesantisperm antibodies
103. ComplicationsComplications
ImmediateImmediate
Haematoma (1-2%)Haematoma (1-2%)
Wound infectionWound infection
(up to 5%)(up to 5%)
FailureFailure
• Due to failure of otherDue to failure of other
contraceptive methods incontraceptive methods in
the initial post-op periodthe initial post-op period
before azoospermia hasbefore azoospermia has
been confirmedbeen confirmed
LateLate
Anti sperm antibody (75%)Anti sperm antibody (75%)
• Thought to be in responseThought to be in response
to leakage of spermto leakage of sperm
• Harmless unlessHarmless unless
restoration of fertility isrestoration of fertility is
desireddesired
Sperm granulomaSperm granuloma
• Presumably also inPresumably also in
response to leaked spermresponse to leaked sperm
• Painful and persistentPainful and persistent
• Can be effectively excisedCan be effectively excised
Chronic testicular painChronic testicular pain
• Unknown causeUnknown cause
105. LAPAROSCOPICLAPAROSCOPIC
STERILISATIONSTERILISATION
Filshie clipFilshie clip
Made of Titanium lined by silicone rubberMade of Titanium lined by silicone rubber
Destroyed 4 mm of tubeDestroyed 4 mm of tube
Failure rate 2-3/1000 proceduresFailure rate 2-3/1000 procedures
Hulka – Clemen clipHulka – Clemen clip
A stainless steel spring with 2 plastic jaws made of LexanA stainless steel spring with 2 plastic jaws made of Lexan
Destroyed about 3 mm of tubeDestroyed about 3 mm of tube
1 year pregnancy rate of 2/1000 women1 year pregnancy rate of 2/1000 women
Falope ringFalope ring
Made of silicon rubber and using special design applicatorMade of silicon rubber and using special design applicator
Placed over the loop of tubePlaced over the loop of tube
It destroyed 2-3cm tube and difficult to applied if tube is thick /It destroyed 2-3cm tube and difficult to applied if tube is thick /
fibroticfibrotic
Ischemia of loop give significant post op painIschemia of loop give significant post op pain
107. 1.The Pomeroy method1.The Pomeroy method
A loop of the isthmic portion of the tube is elevated usingA loop of the isthmic portion of the tube is elevated using
babcock and ligated and cut at its base.babcock and ligated and cut at its base.
The cut ends of the tube are cauterizedThe cut ends of the tube are cauterized
109. 2. The Parkland technique2. The Parkland technique
A 2-3 cm fenestration is made beneath the isthmicA 2-3 cm fenestration is made beneath the isthmic
portion of the tubeportion of the tube
Tube is ligated at both sites , 3cm apart.Tube is ligated at both sites , 3cm apart.
3cm portion of the tube is removed3cm portion of the tube is removed
Care must be taken not to pull on the suture duringCare must be taken not to pull on the suture during
ligation or during transection of the tube because thisligation or during transection of the tube because this
can lead to shearing of the tube from underling mesentrycan lead to shearing of the tube from underling mesentry
resulting in bleedingresulting in bleeding
111. 3.The Uchida method3.The Uchida method
Injection of vaso-constricting solution beneath the serosaInjection of vaso-constricting solution beneath the serosa
of the tube about 6 cm from the utero-tubal junction.of the tube about 6 cm from the utero-tubal junction.
The tube is ligated proximally and distally about 3cmThe tube is ligated proximally and distally about 3cm
apart and cut.apart and cut.
Ligated proximal stump is allowed to retract into theLigated proximal stump is allowed to retract into the
mesosalphinx and tmesosalphinx and the mesosalphinx is closed withhe mesosalphinx is closed with
purse-string suture.purse-string suture.
Ligated distal stump remained exteriorized.Ligated distal stump remained exteriorized.
113. 4. The Irving method4. The Irving method
A fenestration is made beneath the tube about 4cm fromA fenestration is made beneath the tube about 4cm from
the utero-tubal junction.the utero-tubal junction.
The tube is ligated proximally and distally about 3cmThe tube is ligated proximally and distally about 3cm
apart and resected.apart and resected.
A deep pocket is created in the myometrium on theA deep pocket is created in the myometrium on the
posterior surface of uterus.posterior surface of uterus.
Ligated proximal end of the tube are sutured deep intoLigated proximal end of the tube are sutured deep into
the myometrial tunnel.the myometrial tunnel.
Ligated distal stump remained exteriorized.Ligated distal stump remained exteriorized.
115. Reversal of sterilisationReversal of sterilisation
Reversal of female sterilizationReversal of female sterilization
Involves laparotomyInvolves laparotomy
Does not always workDoes not always work
Microsurgical techniques are associated with aroundMicrosurgical techniques are associated with around
70% success70% success
Carries a significant risk of ectopic pregnancy (up toCarries a significant risk of ectopic pregnancy (up to
5%)5%)
Reversal of vasectomyReversal of vasectomy
Technically feasible in many cases with patency ratesTechnically feasible in many cases with patency rates
of almost 90%of almost 90%
Pregnancy rates are much less (up to 60%) perhapsPregnancy rates are much less (up to 60%) perhaps
as a result of the presence of antisperm antibodiesas a result of the presence of antisperm antibodies
117. 1.Quinacrine1.Quinacrine
Blind introduction of pellets of quinacrine into theBlind introduction of pellets of quinacrine into the
uterine cavity via an intrauterine device inserter.uterine cavity via an intrauterine device inserter.
The pellets dissolve near the both cornua, withThe pellets dissolve near the both cornua, with
some solution entering the tubes and causing asome solution entering the tubes and causing a
fibrotic reactionfibrotic reaction
It involves the insertion of 252mg of quinacrineIt involves the insertion of 252mg of quinacrine
on two occasions one month aparton two occasions one month apart
Quoted efficacy of 98% at 2 yearsQuoted efficacy of 98% at 2 years
118. 2.Ovabloc2.Ovabloc
intra-tubal deviceintra-tubal device
Mainly confined to a few centres in theMainly confined to a few centres in the
NetherlandsNetherlands
The procedures involves high pressure injectionThe procedures involves high pressure injection
of viscous silicone into the ostium via a catheter.of viscous silicone into the ostium via a catheter.
The silicone conforms to the shape of theThe silicone conforms to the shape of the
ampulla of the tube and cures in approximately 5ampulla of the tube and cures in approximately 5
minutes.minutes.
119. 2.Ovabloc2.Ovabloc
intra-tubal deviceintra-tubal device
The silicone contains radio-opaque silverThe silicone contains radio-opaque silver
powder which enables a radiological check forpowder which enables a radiological check for
correct placementcorrect placement
Bilateral placement takes around 30 minutesBilateral placement takes around 30 minutes
The woman is asked to use contraception for 3The woman is asked to use contraception for 3
months, at which point a further plain X-ray ismonths, at which point a further plain X-ray is
performed to exclude migration and expulsionperformed to exclude migration and expulsion
Published data reported insertion failure rate atPublished data reported insertion failure rate at
17%17%
In women with a successful insertion the plugIn women with a successful insertion the plug
was expelled in 5% of caseswas expelled in 5% of cases
120. EssureEssure®®
The procedure involves the hysteroscopicThe procedure involves the hysteroscopic
application of a micro-insert into theapplication of a micro-insert into the
intramural portion of the fallopion tubeintramural portion of the fallopion tube
Each device consists of a 4 cm longEach device consists of a 4 cm long
nickle-titanium alloy outer coil withinnickle-titanium alloy outer coil within
which lie polyethylene terephthalate(PET)which lie polyethylene terephthalate(PET)
fibresfibres
The procedure time from insertion toThe procedure time from insertion to
removal of the hysteroscope is around 9removal of the hysteroscope is around 9
minutesminutes
Widely used in Australia, USA and theWidely used in Australia, USA and the
EuropeEurope
121. The PET fibres induce a fibrous reaction inThe PET fibres induce a fibrous reaction in
the tube whick peaks at around 3 weeks.the tube whick peaks at around 3 weeks.
Patients are instructed to use alternativesPatients are instructed to use alternatives
contraception for 3 months after thecontraception for 3 months after the
procedure.procedure.
A plain X-ray or HSG is done at this point toA plain X-ray or HSG is done at this point to
check continued correct placement.check continued correct placement.
99.74% effectiveness with usage over 599.74% effectiveness with usage over 5
yearsyears
122. BARRIER METHODSBARRIER METHODS
• Act by blocking the progress of sperm fromAct by blocking the progress of sperm from
male partner to female thereby preventingmale partner to female thereby preventing
fertilizationfertilization
• Effective in preventing pregnancy and offerEffective in preventing pregnancy and offer
protection against STIs and HIVprotection against STIs and HIV
123. Barrier contraception andBarrier contraception and
spermicidesspermicides
MaleMale
Male condomMale condom
LatexLatex
polyurethanepolyurethane
FemaleFemale
Female condomFemale condom
DiaphragmDiaphragm
Cervical capCervical cap
spongesponge
124. 1.Male condom1.Male condom
• Estimated 44 million couples use
this method
• Japan accounts for more than a
quarter
• Despite the massive problem of
HIV/AIDS, condom use remains low
in Africa, Latin America and Middle
East.
125. Male condomMale condom
• To control HIV/AIDS epidemic, it was
calculated, 24 billion condoms need
to be used/year, this figure not yet
reached 10 billion
126.
127. Male condomMale condom
Failure rate reduce significantly when used correctly byFailure rate reduce significantly when used correctly by
well motivated individualwell motivated individual
Failure rate 2-15/100 women yearsFailure rate 2-15/100 women years
Men complain that they dislike condoms due to lack ofMen complain that they dislike condoms due to lack of
sensitivity around glans of penissensitivity around glans of penis
Advantages of Polyurethane condomsAdvantages of Polyurethane condoms
are baggier and less restrictive around the glans of the penis,are baggier and less restrictive around the glans of the penis,
giving more sensationgiving more sensation
Not affected by fat soluble products like baby oils which wouldNot affected by fat soluble products like baby oils which would
cause breakage of latex condomcause breakage of latex condom
128.
129. 2. Female condom2. Female condom
FemidomFemidom
Made of polyurethaneMade of polyurethane
Come in 1 sizeCome in 1 size
Lines the vaginaLines the vagina
An internal ring in the closedAn internal ring in the closed
end of the pouch covers theend of the pouch covers the
cervix and an external ringcervix and an external ring
remains outside the vagina,remains outside the vagina,
partially covering the perineumpartially covering the perineum
Prelubricated with silicone andPrelubricated with silicone and
spermicide need not to bespermicide need not to be
usedused
Design for single use and isDesign for single use and is
expensiveexpensive
Failure rate is 5 – 20 per100Failure rate is 5 – 20 per100
women yearwomen year
130. 3. Diaphragm3. Diaphragm
Consist of thin, latex rubber hemisphere, rimConsist of thin, latex rubber hemisphere, rim
reinforced by flexible flat or coiled metalreinforced by flexible flat or coiled metal
springspring
Should lie diagonally across cervix reachingShould lie diagonally across cervix reaching
post vaginal fornix to behind symphysis pubispost vaginal fornix to behind symphysis pubis
covering the cervix.covering the cervix.
Causes of failure areCauses of failure are
Poor motivationPoor motivation
Incorrect insertionIncorrect insertion
Displacement during SIDisplacement during SI
To increase effectiveness use withTo increase effectiveness use with
spermicidal is advised (Smith et al 1995)spermicidal is advised (Smith et al 1995)
Failure rateFailure rate
With spermicidal is 4-8 per 100 womenWith spermicidal is 4-8 per 100 women
yearsyears
Without spermicidal is 10-18 per 100Without spermicidal is 10-18 per 100
women yearswomen years
131. 4. Cervical cap4. Cervical cap
FEMCAPFEMCAP
Need not to be used withNeed not to be used with
spermicidespermicide
Made of nonallergic siliconeMade of nonallergic silicone
rubber.rubber.
Shaped like an American sailor’sShaped like an American sailor’s
hathat
Design to conform to the naturalDesign to conform to the natural
shape of the cervix; the brimshape of the cervix; the brim
around the cap helps to create aaround the cap helps to create a
seal around the vaginal wall,seal around the vaginal wall,
stopping the sperm from enteringstopping the sperm from entering
the cervixthe cervix
3 sizes3 sizes
22mm suitable for nulliparous22mm suitable for nulliparous
26mm suitable for woman who26mm suitable for woman who
have been pregnant beforehave been pregnant before
30mm suitable for women have30mm suitable for women have
had a vaginal deliveryhad a vaginal delivery
Failure rate is 8 – 20 per 100Failure rate is 8 – 20 per 100
women yearswomen years
132. DiaphragmDiaphragm CapCap FemaleFemale
condomcondom
Insertion beforeInsertion before
coitus no longercoitus no longer
thanthan
6 hrs6 hrs 6 hrs6 hrs 8 hrs8 hrs
After coitusAfter coitus
should be left inshould be left in
place forplace for
6 hrs6 hrs 8 hrs8 hrs --
Maximal wearMaximal wear
timetime
24 hrs24 hrs 48hrs48hrs 8hrs8hrs
133. 5.Vaginal sponge5.Vaginal sponge
Marketed asMarketed as ProtectaidProtectaid
Can be inserted into the vagina up to 6 hours beforeCan be inserted into the vagina up to 6 hours before
sexual intercourse and can be left for a maximum of 12 hsexual intercourse and can be left for a maximum of 12 h
Impregnated with a spermicide called F-5gelImpregnated with a spermicide called F-5gel
efficacy of 90% with careful and consistent useefficacy of 90% with careful and consistent use
Should be inserted 15 min prior to sexual intercourseShould be inserted 15 min prior to sexual intercourse
Sexual intercourse may take place more than onceSexual intercourse may take place more than once
without the need to replenish the spermicidewithout the need to replenish the spermicide
Should be left in situ for 6 h after the last episode ofShould be left in situ for 6 h after the last episode of
sexual intercoursesexual intercourse
134. 6.SPERMICIDES6.SPERMICIDES
A type of contraceptive agentA type of contraceptive agent
that work by killing sperm.that work by killing sperm.
It need to be in place in aIt need to be in place in a
woman's vagina beforewoman's vagina before
intercourse if they are tointercourse if they are to
prevent viable sperm fromprevent viable sperm from
reaching her uterus.reaching her uterus.
It come in a wide variety ofIt come in a wide variety of
forms, including pessaries,forms, including pessaries,
creams, foams.creams, foams.
The active ingredient in allThe active ingredient in all
spermicides isspermicides is Nonoxynol-9.Nonoxynol-9.
136. 1. PERIODIC A1. PERIODIC ABSTINENCEBSTINENCE
Also known asAlso known as ovulation method, Rhythm method orovulation method, Rhythm method or
Calender method or Fertility awareness methodCalender method or Fertility awareness method
Based on the assumption that menstrual cycle relativelyBased on the assumption that menstrual cycle relatively
constant and the viability of sperm in the femaleconstant and the viability of sperm in the female
reproductive tract (2-7 days) and the life span of ovum(1-reproductive tract (2-7 days) and the life span of ovum(1-
3 days)3 days)
Pregnancy rate of 40 per 100 women yearsPregnancy rate of 40 per 100 women years
General ruleGeneral rule
To estimate the beginning of fertile period by substracting 18To estimate the beginning of fertile period by substracting 18
days from the length of the shortest cycledays from the length of the shortest cycle
To estimate the end of fertile period by substracting 11 days fromTo estimate the end of fertile period by substracting 11 days from
the longest cyclethe longest cycle
Example is if cycles of 28-32 days, periodic abstinence shouldExample is if cycles of 28-32 days, periodic abstinence should
be from day 10 to day 21be from day 10 to day 21
137. 2. Coitus interruptus2. Coitus interruptus
Means withdrawal of the penis from vagina justMeans withdrawal of the penis from vagina just
before ejaculation to prevent pregnancy.before ejaculation to prevent pregnancy.
But it is not reliable as pre-ejaculatory secretionsBut it is not reliable as pre-ejaculatory secretions
may contain millions of sperm.may contain millions of sperm.
138. 3. Hormone monitoring3. Hormone monitoring
PERSONAPERSONA
A hand held monitor with disposable urine dip stickA hand held monitor with disposable urine dip stick
Measures levels of LH and oestrogen in early morningMeasures levels of LH and oestrogen in early morning
urineurine
The ratio between the 2 hormones is used to defined theThe ratio between the 2 hormones is used to defined the
start and the end of fertile phasestart and the end of fertile phase
A red light is displayed on days when intercourse shouldA red light is displayed on days when intercourse should
be avoidedbe avoided
Need to be programmed for 3 months ( test urine for 16Need to be programmed for 3 months ( test urine for 16
days in the first month and 8 days in subsequentdays in the first month and 8 days in subsequent
months) before device can be relied uponmonths) before device can be relied upon
Failure rateFailure rate ~6/100 woman years with perfect use.~6/100 woman years with perfect use.
139. 3. Hormone monitoring3. Hormone monitoring
PERSONAPERSONA
Not suitables for:Not suitables for:
Cycle length <23 days or > 35 daysCycle length <23 days or > 35 days
PCOSPCOS
BreastfeedingBreastfeeding
Menopausal symptomsMenopausal symptoms
Women taking hormonal medicationWomen taking hormonal medication
140. 4. Cervical mucus method4. Cervical mucus method
Also known asAlso known as Billing methodBilling method
Requires sensing and observing the cervical mucusRequires sensing and observing the cervical mucus
changes over timechanges over time
Oestrogen induced changes at mid cycle: Increase inOestrogen induced changes at mid cycle: Increase in
amount of clear, thin and stringy mucusamount of clear, thin and stringy mucus
With ovulation and in the presence of progesterone,With ovulation and in the presence of progesterone,
mucus becomes opaque, sticky and much less stretchymucus becomes opaque, sticky and much less stretchy
or disappear all togetheror disappear all together
The of ovulation correspond closely to the day of peakThe of ovulation correspond closely to the day of peak
mucusmucus
Intercourse is permitted on theIntercourse is permitted on the 44thth
day after the last dayday after the last day
of sticky, wet mucusof sticky, wet mucus
141. 5.Sympto-thermal method5.Sympto-thermal method
Basal body temperatureBasal body temperature
It is recorded before getting out of bed (early in the morning)It is recorded before getting out of bed (early in the morning)
Progesterone secretion is associated with a rise in basal bodyProgesterone secretion is associated with a rise in basal body
temperature of about 0.5temperature of about 0.5°C°C
Prior to ovulation the temp is usually below normal bodyPrior to ovulation the temp is usually below normal body
temperaturetemperature
If practice alone, it requires abstinence until the night of 3If practice alone, it requires abstinence until the night of 3rdrd
day ofday of
a shift in temperaturea shift in temperature
Combining the basal body temperature with the mucusCombining the basal body temperature with the mucus
methodmethod
abstinence begins when the mucus becomes sticky and moist.abstinence begins when the mucus becomes sticky and moist.
Intercourse resumes the night of either the 3Intercourse resumes the night of either the 3rdrd
day of a temp shiftday of a temp shift
or the 4or the 4thth
day after the last day of sticky, wet mucus which ever isday after the last day of sticky, wet mucus which ever is
laterlater
142. CONTRACEPTIVECONTRACEPTIVE
VACCINESVACCINES
Research on vaccines has focused on threeResearch on vaccines has focused on three
targets:targets:
1.1. human chorionic gonadotropin (hCG),human chorionic gonadotropin (hCG),
2.2. the sperm-binding glycoprotein in the zonathe sperm-binding glycoprotein in the zona
pellucida of the egg, andpellucida of the egg, and
3.3. sperm.sperm.
Research on vaccines has been ongoing forResearch on vaccines has been ongoing for
decades; many problems must be overcome,decades; many problems must be overcome,
including inducing autoantibodies.including inducing autoantibodies.
143. Current status of FRV (fertilityCurrent status of FRV (fertility
regulating vaccinesregulating vaccines ))
developmentdevelopment
Anti-sperm vaccinesAnti-sperm vaccines
Sperm enzymes.Sperm enzymes.
Sperm membrane antigens.Sperm membrane antigens.
Anti-ovum vaccinesAnti-ovum vaccines
Anti-conceptus vaccinesAnti-conceptus vaccines
Structural placental antigens.Structural placental antigens.
Hormonal placental antigens.Hormonal placental antigens.
144. Mechanism of action,Mechanism of action,
reversibility and choicereversibility and choice
FRVs could act by preventing spermFRVs could act by preventing sperm
production, by interfering with ovulation,production, by interfering with ovulation,
by inhibiting fertilization, or by preventingby inhibiting fertilization, or by preventing
implantation of the blastocyst. It isimplantation of the blastocyst. It is
important that studies are carried out toimportant that studies are carried out to
clearly determine how each FRV works.clearly determine how each FRV works.
By understanding their mechanisms ofBy understanding their mechanisms of
action, more efficient and predictableaction, more efficient and predictable
FRVs can be prepared and rationalFRVs can be prepared and rational
intervention strategies can be developedintervention strategies can be developed
to reverse the effects of the FRVs onto reverse the effects of the FRVs on
demand.demand.
145. Mechanism of action,Mechanism of action,
reversibility and choicereversibility and choice
In addition, the user would be able to beIn addition, the user would be able to be
fully informed of the known or suspectedfully informed of the known or suspected
mechanisms of action of FRVs so that hemechanisms of action of FRVs so that he
or she can choose a FRV that isor she can choose a FRV that is
compatible with their personal beliefs andcompatible with their personal beliefs and
needs.needs.
146. Future prospects and needsFuture prospects and needs
Vaccine optimizationVaccine optimization
Long-term safetyLong-term safety
147. Contraceptive Methods and Cancer RiskContraceptive Methods and Cancer Risk
Method
Breast
Cancer
Cervical
Cancer
Endometrial
Cancer
Ovarian
Cancer
Oral contraceptive ?
Vaginal ring NA NA NA NA
Contraceptive patch NA NA NA NA
Condom — — —
Diaphragm — — —
Injectable
contraceptive
— — —
Intrauterine device — —
Abstinence — — —
Fertility awareness — — — —
Sterilization —
NA= research has not been conducted on the cancer–related risk of this method
148. Failures of contraceptionFailures of contraception
METHOD OF CONTRACEPTION FAILURE RATE PER 100
WOMAN YEARS
Combined oral contraceptive pills 0.1-1
Progestogen-only pills 1-3
Depo-Provera® 0.1-2
Implanon® 0.1
Copper IUD 1-2
Mirena® 0.5
Male condom 2-5
Diaphragm 1-15
Natural family planning 2-3
Vasectomy 0.02
Female sterilization 0.13
