family planning methods

1. FAMILY PLANNINGFAMILY PLANNING
AYMAN SHEHATAAYMAN SHEHATA
Lecturer of Ob/GynLecturer of Ob/Gyn
Tanta UniversityTanta University

2. IDEAL CONTRACEPTIVEIDEAL CONTRACEPTIVE
 InexpensiveInexpensive
 Easy and simple to use with minimum sideEasy and simple to use with minimum side
effectseffects
 Rapidly reversibleRapidly reversible
 Readily availableReadily available
 Highly effective.?Highly effective.?
 Can be administered by non-healthcareCan be administered by non-healthcare
personnel.personnel.

3. Contraceptive effectivenessContraceptive effectiveness
Difficult to determine :Difficult to determine :
1.1. Perfect VS typical use (method failure andPerfect VS typical use (method failure and
patient failure)patient failure)
2.2. Correct VS incorrect useCorrect VS incorrect use
3.3. Long term VS short termLong term VS short term

4. Pearl indexPearl index
Method used for determination of pregnancyMethod used for determination of pregnancy
failure rate:failure rate:
Pregnancy rate = no. of pregnanciesPregnancy rate = no. of pregnancies
x100women/12 months of usex100women/12 months of use

5. classificationsclassifications
A. Natural MethodsA. Natural Methods
Periodic abstinencePeriodic abstinence
Withdrawal methodWithdrawal method
Lactational Amenorrhea MethodLactational Amenorrhea Method
B. Barrier MethodsB. Barrier Methods
C. HormonalC. Hormonal
D .Intrauterine DevicesD .Intrauterine Devices
E.. SterilizationE.. Sterilization

6. HORMONALHORMONAL
CONTRACEPTIONCONTRACEPTION

7. TypesTypes
 Combined pillsCombined pills
 Progestin pills (minipills)Progestin pills (minipills)
 Subdermal implantsSubdermal implants
 InjectionsInjections
 Vaginal ringVaginal ring
 Skin patchesSkin patches
 Medicated IUDsMedicated IUDs

8. Combined Oral contraceptive pillsCombined Oral contraceptive pills
World wide usedWorld wide used
very convenient methodvery convenient method
Reversible methodsReversible methods

9. Combined pills(COCs)Combined pills(COCs)
Composition
Combination of Estrogen & Progesterone
ESTROGENS: Ethinyl Estradiol (most commonly
used nowadays) and mestranol
PROGESTRONE: Levonorgestrel, Norethindrone,
Gestodine,Norgestimate
Intake
21 days: 1 pill/day
Last 7 days: free

10. Effectiveness
Failure rate is 0.2-0.5
per 100 woman years

11. Mechanism of actionMechanism of action
most effective method because they inhibit midcyclemost effective method because they inhibit midcycle
gonadotropin surge and prevent ovulationgonadotropin surge and prevent ovulation
**Interfere with the release of GnRH from hypothalamus so it willInterfere with the release of GnRH from hypothalamus so it will
suppress LH & FSHsuppress LH & FSH
*In high concentration they will inhibit pituitary gland directly*In high concentration they will inhibit pituitary gland directly
Altering cervical mucus making it thick viscid and scantyAltering cervical mucus making it thick viscid and scanty
Alter endometrium so not recptive for implantationAlter endometrium so not recptive for implantation
Alter ovarian responsiveness to gonadotropin stimulationAlter ovarian responsiveness to gonadotropin stimulation

13. formulations
Monophasic
– fixed amount of an oestrogen and a
progestogen in each active tablet
Biphasic
pills deliver the same amount of estrogen every day for the first 21 days of the cycle. During the firstpills deliver the same amount of estrogen every day for the first 21 days of the cycle. During the first
half of the cycle, the progestin/estrogen ratio is lower to allow the lining of the uterushalf of the cycle, the progestin/estrogen ratio is lower to allow the lining of the uterus
(endometrium) to thicken as it normally does during the menstrual cycle. During the second half(endometrium) to thicken as it normally does during the menstrual cycle. During the second half
of the cycle, the progestin/estrogen ratio is higher to allow the normal shedding of the lining of theof the cycle, the progestin/estrogen ratio is higher to allow the normal shedding of the lining of the
uterus to occur.uterus to occur.
Triphasic
-amounts of the two hormones varies twice
according to the stage of the cycle
ED (every day)
– includes 7 days of placebo tablets

18. Types of progestogens
1st
generation: norethindrone,norethindrone acetate, ehynodiol diacetate
2nd
generation : Norgesteryl , levenorgesteryl
3rd
generation : desorgestrel , gestodene,Norgestimate
4th
generation : drosperinone, dienogest

19. Norgestimate Cilest (35 EE)
Desogestrol Marvelon 30 EE
Gestogene Gynera 30EE
Drospirenone Yasmin (30 EE)

24. Starting Regimes
Menstruating Ideally start day 1 of cycle can start up to day 5 without additional
contraception
Anytime if no unprotected intercourse since LMP but additional
protection for 7 days
Postpartum Non breast feeding - Start Day 21. if after day 21 additional method
for 7 days
Breast feeding - Start 6 months
Miscarriage/
TOP< 24wks
Same or next day. If started > 7 days after then additional method
for 7 days
TOP > 24wks Start on day 21, otherwise if later then additional method for 7
days
Amenorrhoea At any time if no risk of pregnancy, and 7 days additional
precautions

25. Side effectsSide effects
Mostly caused by progestinMostly caused by progestin
NauseaNausea
Breast tendernessBreast tenderness
Fluid retentionFluid retention
DepressionDepression
HeadacheHeadache
acneacne

26. Side effectsSide effects
Estrogen cause pigmentationEstrogen cause pigmentation
Accelerate the development of gallbladderAccelerate the development of gallbladder
disease in young female but not increase thedisease in young female but not increase the
risk of acute cholelithiasisrisk of acute cholelithiasis

27. NONCONTRACEPTIVE BENEFITSNONCONTRACEPTIVE BENEFITS
1. Cycle regulation
2. Decreased menstrual flow
3. Increased bone mineral density
4. Decreased dysmenorrhea
5. Decreased peri-menopausal symptoms
6. Decreased acne
7. Decreased hirsutism
8. Decreased endometrial cancer
9. Decreased ovarian cancer
10. Decreased risk of fibroids
11. Postpone menses
12. Possibly fewer ovarian cysts
13. Possibly fewer cases of benign breast disease
14. Decreased incidence of salpingitis
15. Decreased incidence or severity of moliminal symptoms

28. RISKS
1.VENOUS THROMBOEMBOLISM
2.MYOCARDIAL INFARCTION
3.CEREBROVASCULAR STROKE
4.BREAST CANCER
5.CERVICAL CANCER

29. ABSOLUTE CONTRAINDICATIONS
1. < 6 weeks postpartum if breastfeeding
2. Smoker over the age of 35 (≥ 15 cigarettes per day)
3. Hypertension (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg)
4. Current or past history of venous thromboembolism (VTE)
5. Ischemic heart disease
6. History of cerebrovascular accident
7. Complicated valvular heart disease
8. Migraine headache with focal neurological symptoms
9. Breast cancer (current)
10. Diabetes with retinopathy/nephropathy/neuropathy
11. Severe cirrhosis
12. Liver tumour (adenoma or hepatoma)

30. RELATIVE CONTRAINDICATIONS
1. Smoker over the age of 35 (< 15 cigarettes per
day)
2. Adequately controlled hypertension
3. Hypertension (systolic 140–159mm Hg,
diastolic 90–99mm Hg)
4. Migraine headache over the age of 35
5. Currently symptomatic gallbladder disease
6. Mild cirrhosis
7. History of combined OC-related cholestasis
8. Users of medications that may interfere with
combined OC metabolism

31. When to Discontinue COCP
At least 4w before major surgery
First onset of migraine with aura
Pain or swelling in legs
Chest pain with breathlessness or haemoptysis
Cigarette smoker >35y
Age 50y

32. MinipillsMinipills
(POPs)(POPs)
Used for 28 days, no breaks
Same time of the day

33. Generations of POP
1st: norethindrone
2nd: norethisterone , levenorgesterol
3rd: desorgestrel , gestodene
4th : drosperinone

36. Mechanism of actionMechanism of action
Altering cervical mucus making it thick viscid and scantyAltering cervical mucus making it thick viscid and scanty
Alter endometrium so not recptive for implantationAlter endometrium so not recptive for implantation
Alter ovarian responsiveness to gonadotropin stimulationAlter ovarian responsiveness to gonadotropin stimulation
Progestin only pills don't inhibit ovulation mainly becauseProgestin only pills don't inhibit ovulation mainly because
a lower dose of progestin is used in preparations less thana lower dose of progestin is used in preparations less than
combined formscombined forms
It is important to be taken at the same time of the day toIt is important to be taken at the same time of the day to
ensure that blood level do not fall below the effective levelsensure that blood level do not fall below the effective levels

37. Efficacy
Failure rate of 0.3-5 per 100 woman
years

38. Indications of POP
< 21 days post partum. 6wks-6mths postpartum partially
or fully BF
Age> 35 and smoke
BMI> 35
Multiple risk for CerebroVascular Stroke
Risk of VTE
Hypertension controlled with medications
DM
Valvular heart problems
CIN/ endometrial cancer/ ovarian cancer
Family History of Breast cancer

39. Contraindications
Uncontrolled hypertension
Active hepatitis/ decompensated cirrhosis/ liver tumours
Mal absorption
Current DVT
Undiagnosed Genital tract bleeding
Recent trophoblastic disease with high bHCG
Current IHD

40. LONG ACTING
CONTRACEPTIONS

41. VAGINAL RINGVAGINAL RING
Steroids absorbed though vaginal epithelium directlySteroids absorbed though vaginal epithelium directly
into circulationinto circulation
Two Types:-
1. Combined estrogen and
progestin vaginal ring
2. Progestin-only vaginal ring
Place in vagina for 21 days and remove 7 days toPlace in vagina for 21 days and remove 7 days to
allow withdrawal bleedingsallow withdrawal bleedings

43. There is no wrong way to insert the ring.
If it lies comfortably in the vagina,
it has been placed correctly.
Vaginal Contraceptive Ring:
Insertion

44. TRANSDERMAL PATCH
It releases norelgestromin & ethinyl estradiol
Weekly applied, for 3 weeks, and the last
week of the cycle is a patch-free week
Normal activities can be done while using the
patch

45. Sites Of Application
- Buttocks
- Upper outer arm
- Back
- Lower abdomen

46. HORMONAL METHODSHORMONAL METHODS
Subdermal implants for continuous release
Effective for up to 3 years
Rapid return of fertility
Problems
Menstrual irregularity
Weight gain
Surgical implantation & removal

48. INJECTABLE SUSPENTIONSINJECTABLE SUSPENTIONS
Depomedroxyprogesteron(DMPA)Depomedroxyprogesteron(DMPA)
IM,SC every 3 monthsIM,SC every 3 months
doesn't increase risk of breast cancerdoesn't increase risk of breast cancer
Other types: medroxyprogesteron acetateOther types: medroxyprogesteron acetate

49. (1)Progestogen-only formulations that contain a
progestogen hormone and are effective for 2
or 3 months(DPV)
(2) Combined formulations that contain both a
progestogen and an estrogen and are effective
for 1 month (Mesigyna)
TYPES

50. Medicated IUDs
Mirena (levonorgestrel-releasing
intrauterine system) is intended to provide
an initial release rate of 20 mcg/day of
levonorgestrel

56. Type Comment
Graefenberg ring --- Lippes loop
Birnberg bow --- Safe-T coil
No longer used
Cu 7
Cu T200 (Tatum T)
No longer used
Cu T380 Ag (ParaGard)
Nova-T (NovaGard)
Long protection
Multiload 375
GyneFix (Frameless Cu-Fix)
Long protection
Progestasert-T
Mirena (LNG medicated)
One year protection
Types of IUCD

59. Old IUDs

61. Contraindication for IUCD
Absolute
Pelvic infection
Pregnancy
Uterine anomaly
Undiagnosed
Bleeding
Relative
Multiple partners
History of ectopic
Impaired CMI
Impaired clotting
Lower genital infection
History of PID
Wilson’s disease

62. Copper IUCD
Acts by blocking fertilization.
Antibiotics cover is recommended
50% abortion rate if left in situ with an
accidental pregnancy
Removal of the device early in pregnancy
reduces abortion rate to 20%
IUCD of whatever type is not the first choice
for nulliparous patient

63. Mechanism of action
All IUDs cause an increase in number of
leucocytes, in endometrium and in uterine
and tubal fluid
The above impedes sperm transport and
fertilisation. Actual phagocytosis of sperm
has been reported
Copper enhances foreign body reaction and
causes biochemical changes in the
endometrium
Copper ions are also directly toxic to sperm
and blastocyst

64. LNG medicated device (Mirena)
Release LNG 20 microgram/day for 5 years
Lower failure rate than copper IUCD
Lower ectopic rate lower than using nothing
Reduces the risk of pelvic infection
Difficult to fit in nulliparous women
Vaginal spotting for first few months of use
Used with ERT to protect from hyperplasia

65. LNG medicated vaginal rings
Vaginal rings are inserted for 6 months
Removed only during menses or coitus
Disadvantages are expulsion and irritation
Medication escape liver inactivation

66. Patient counsellingPatient counselling

67. IUD Counseling Topics
• Characteristics of IUDs
• Client’s risk of STIs
• Effectiveness and how the IUD works
• Insertion and removal procedures
• Instructions for use and follow-up visits
• Possible side effects and complications
• Signs of possible complications

69. InsertionInsertion

70. Insertion
History
Examination
Cavimetry
Technique
Sonographic assessment
Advice
– Menstruation
– Stringes
– Dangerous symptoms
Follow-up
Timing of insertion
Interval
Postmenstrual
Menstrual
Postpartum
Immediate
4-weeks
Postabortive
Immediate
4-weeks

72. IUD Insertion and removal

73. Complication of IUCD
Failure 5/HWY
Perforation 1/1000 insertions
PID the risk is high in the first weeks
Bleeding
Pain
Expulsion

74. IUD warning Signals
PAINS
Period late
– Pregnancy
Abdominal pain
– Expulsion
Infection
– PID
Not feeling well
– Fever, chills
String missing
– Lost IUD

75. Pregnancy
Pregnancy can occur with device in
place
This pregnancy may be eutopic or
ectopic
Do not remove device with lost thread
Device left in place carry these risks
–Abortion (50%)
–APH
–PML
–IUFD

76. IUD-related PID
The risk is due to
–Asepsis during application
–Bacteria gain access via the device
You have to screen for STD
IUCD is contraindicated
–Multiple partner
–History of PID

77. Perforation
This is a rare event
Occurs at insertion
The risk is high
–Poor skill of the provider
–Postpartum insertion

78. Expulsion
Low insertion
Large cavity
Postpartum insertion
Poor skill of the provider

79. Lost thread
Arrange for ultrasound examination
– Device may be expelled
– Device may escaped
– Device may be retrieved
Arrange for removal
– Thread-retrieval hook
– Sponge forceps
– Endoscopic guided

80. Sonography for lUCD

81. Removal
Start an alternative method before
removal
Causes of removal
– Desire for pregnancy
– Device is no longer protective
– Device is no longer needed
– Complications

83. THANK YOUTHANK YOU