2. The ideal reversible
contraception
 100% effective after a single simple procedure
 100% safe with no danger or unwanted side
effects
 Independent of the medical professions
 100% reversible by simple procedure
 Independent of coitus
 Not relying on user motivation
 Cheap and easy to distribute
 Pre fertilisation in action
 Used by or visible to the woman
 Additional beneficial effects

3. The balance of advantage
 The efficacy of the method
 The patient’s wishes
 The advantages and disadvantages of the
method
 Medical problems

4. Failure rates during the first year of contraceptive use
(USA 1995- National survey)
Method
Female sterilisation
IUD-LNG
Male sterilisation
Implant
IUD-Copper T380A
IUD- progesterone
POP
Injectable
COC
Diaphragm and spermicides
Male condom
Cervical cap-Nulliparous
Sponge- nulliparous
Periodic abstinence
Female condom
Withdrawal
Spermicides
Cervical cap-parous
Sponge- parous
No method
Ideal use(per cent)
Typical use(per cent)
0.05
0.1
0.1
0.05
0.6
1.5
0.5
0.3
0.1
6.0
3.0
9.0
9.0
0.05
0.1
0.15
0.2
0.8
2.0
3.0
3.1
7.6
12.1
13.9
20.0
20.0
20.5
21.0
23.6
25.7
40.0
40.0
85
5.0
7.0
6.0
20.0
20.0
85

5. Relative popularity with
different methods(U.K.)









COCP ------------------------ 36%
Barrier methods--------------21%
Vasectomy -------------------16%
Female sterilisation --------- 10%
IUCD ------------------------- 7%
O.C. with barrier ------------ 3%
NFP --------------------------- 2%
CI ------------------------------ 1%
No method ------------------- 4%

6. Medical conditions which contraindicate the
use of a contraceptive method
(WHO classification 1994)
 A condition in which there is no restriction for
the use of the contraceptive method
 A condition where the advantage of the method
generally outweighs the theoretical or proven
risks
 A condition where the theoretical or proven risks
usually outweigh the advantages. But if the
patient accepts the risks and rejects or should not
use relevant alternatives, the method can be used
with caution/ additional care
 A condition which represents unacceptable health
risks.

7. Mechanism of action and
biologic activity of COC
 Inhibition of ovulation through combined action
of progestogen and oestrogen
 Dominant component is progestogen:
Suppresses LH release
Creates thick cervical mucous
Inhibits capacitation
 Oestrogen- suppresses FSH and LH release
-Accelerates ovum transport
-Alters secretion affecting
implantation

8. Oestrogen induced alterations
in the blood





Encourages venous thrombo-embolism
Reduced anti-thrombin3
Elevated fibrinogen
Elevated Vit.K dependent coagulation factors
Increased fibrinolytic activity
 In the presence of significant arterial wall
disease, oestrogen may also promote
superimposed arterial thrombosis
 Elevated blood lipids with reduced HDLcholesterol

9. Effect of COCP on the Liver
 The liver is affected in more ways than any other
extra-genital organ
 Active transport of biliary constituents is
impaired by both Oestrogen and Progestogen
 The mechanism is unclear, but cholestatic
jaundice and pruritus are associated with the
COCP
 The COCP can cause an increase in cholesterol
saturation of the G.B. bile with an increased
incidence of gall stones
 Benign hepatic adenomas are associated with the
COCP
 A few cases of hepato-cellular cancer have been
reported

10. Absolute contraindications to the COC
(WHO System 1994)
 Cardiovascular
 Venous thrombosis- h/o thromboembolic
disorders or close family history
 Arterial thrombosis- angina, MI
 Cerebral thrombosis or haemorrhage
 Severe hypertension
 Elective major surgery
 Leg immobilisation
 Hyperlipidemia (Cholesterol > 8mmol/l)
 Congenital or acquired heart disease

11. Absolute contraindication to COC
(WHO System 1994)
Cardiovascular
 Focal migrane or status migranous
 Transient ischaemic attacks
 Coagulation tendency
- thrombophylias
•
•
•
•
- Fac. V Leiden mutation
- Phospholipid syndrome
- activated protein C resistance
- blood dyscrasias
- some autoimmune/ rheumatoid disorders
- Post-splenectomy (platelets > 500 x 109)
Severe inflammatory bowel disease- Chron’s, Ulcerative colitis
Opthalmic vascular disease
Exposure to high altitude
Combination of risk factors

12. Absolute contraindications to
COC
Hepatic
 Acute liver disease (whenever LFTs abnormal)
 Chronic liver disease
 Cholestatic jaundice of pregnancy or OC
associated
 Chronic idiopathic jaundice
 History of liver adenoma, carcinoma
 Focal nodular hyperplasia
 Galstones causing symptoms
 The acute porphyrias

13. Absolute contraindications to COC
Other
 Known or suspected oestrogen dependent neoplasia
 Serious condition affected by sex steroids
- pemphigoid gestationis
- Haemolytic uraemic syndromes
- Pancreatitis
- Hypertrigliceridaemia
- Chorea
- Erythema multiforme
- Thrombocytopenic purpura
 Undiagnosed abnormal vaginal bleeding
 Pregnancy
 Throphoblastic disease
 Continuing anxiety unrelieved by counselling

14. Relative contraindication to
COC
 Women over 35, who smoke
 Essential hypertension, but controlled on
treatment
 Latent or established diabetes mellitus
 Cholelithiasis, but can be used after
cholecystectomy
 Young, first degree relative with breast cancer
 Obesity, if associated with other risk factors
 Non- focal migraine when ergotamine not
required
 Sickle cell disease
 Chron’s Disease

15. Reduced OC efficacy due to
interactions
 Gastroenteritis
  impaired absorption of
OC
 Drugs causing induction
of hepatic enzymes
  ↑ metabolite activity
& ↑ elimination in bile of
both oestrogen and
progesterone
 Some anti-epileptics:
- phenobarbitone
- carbamazepine
- phenytoin
- primidone
  use alternative method
IUD or IUS or 50µg
containing OC

16. Reduced OC efficacy due to
interactions
 Anti- TB:
- Rifampicin
  very potent enzyme inducer
  use DMPA with 8 week
injection interval or alternate
method
  wait 8 weeks after end of
course before recommencing
COC
 Antibiotics causing
change in bowel flora:
- Penicillin
- Tetracyclines
- Cephalosporins
  OC are conjugated in the
liver, excreted in the bile and
partly reabsorbed. If gut
bacteria are inhibited by
antibiotics, reabsorption may
not occur

17. Other drugs that may reduce
efficacy of COC
 Cholesterol lowering
agents
 ↓ cholesterol and
triglycerides
 ↓ OC efficacy
 Sedatives and hypnotics
 Enzyme inducer
 Antacids
retroviral
 ↓ intestinal absorption:
take 2 hours apart
 Do not use COCs

18. Drugs that may increase COC
level
 Paracetamol
 Completes in bowel wall
for conjugation to
sulphate
⇒possible more O2
available for absorption:
take 2 hours apart
 erythromycin
* Potent inhibitor of
oestradiol metabolism

19. Modification of other drug
action by OC








Alcohol
Anticoagulants
Aminocaproic acid
Caffeine
Corticosteroids
Cyclosporine
Phenothyzines
Sedatives/ hypnotics
 Tricyclic
antidepressants
 Vitamine B12
 Beta blockers
 antipyretics

20. Medical disorders for which
COCP prescribed











Spasmodic dysmenorrhoea
Menstrual irregularities
Premenstrual tension
Menorrhagia (even with fibroid) and anaemia
Endometriosis
Functional ovarian cysts
Ovulation pain
Oestrogen deficiency
PCOS
Acne
Prophylaxis against ovarian carcinoma

21. Other non contraceptive benefits
of the COCP
 Prevents ectopic pregnancies
 Reduces incidence of benign breast disease
 ? Reduces fibroid size and menorrhagia
 Protects against ovarian and endometrial
carcinoma

22. Mechanism of action of POPs
 Inhibition of ovulation in at least 60% and
more often in older women
 Alteration in cervical mucous
 Inhibits capacitation

23. Indications for POP









During lactation
Contraindications to or side effects with COCP
Hormonal method preferred
Women > 35 years old who smoke
Chronic systemic disease which oestrogen might
exacerbate (SLE,Chron’s disease,Ulcerative
Colitis)
Diabetes
Hypertension
Migraine
Preference

24. Contraindications to POP
 Severe arterial wall disease
or at risk of :– Liver adenoma or carcinoma
– Severe cholestatic jaundice
– Recent trophoblastic disease
– Acute porphyria

25. Indications for IUCD










Effective
Safe
Indepent of coitus
No effort required
Motivation necessary only at time of insertion
Relatively cheap and easy to distribute
Does not influence milk volume/composition
Under woman’s control
Continuation rates high
Nearly always reversible

26. Contraindications to IUCD
 Pregnancy
 Serious related pregnancy related infection
within previous year
 Acute pelvic inflammatory disease
 Significant uterine abnormality
 Severe dysmenorrhoea
 Undiagnosed uterine bleeding
 Carcinoma of cervix or endometrium
 Previous ectopic pregnancy
 Risk from bacteraemia
e.g. valvular heart disease
renal dialysis
immunosuppressive drugs

27. Relative contraindications to
IUCD
 Past history of STDs
 Multiple sexual partners
 Menorrhagia
 Copper allergy

29. Subdermal implants
 Jadelle (2 rods) or Implanon are now available
 (Norplant is no more!)
 Work by ovulation inhibition, supplemented by
the usual mucus and endometrial effects
 Last 3 years
But tissue levels are lower in heavier women especially by 3rd year
⇒re- implant sooner

30. Advantages of subdermal implant










Efficacy and convenience
Long action
Absence of initial peak dose given orally
Blood level steady
HDL/LDL ratio and clotting factors unchanged
No concern regarding past history of venous
thrombosis
Excellent choice for Diabetics
No effect on blood pressure
Can be used with past ectopic history
Rapidly reversible

31. Disadvantages of Implants




Altered bleeding pattern- 18%
Frequent bleeding and spotting
(Treat with cyclical COCP therapy)
Minor side effects- acne, headache, breast pain,↓
libido
 Weight ↑- 35% put on 3 kg
 Possible hypo-oestrogenaemia- because
ovulation suppressed and no oestrogen supplied
 Local adverse effects

32. Advantages of injectables
 High effectiveness - > than COCP
 Freedom from fear of forgetting
 Highly convenient- not coitus-related
 Fully reversible (though some delay)

33. Disadvantages of injectables










Irreversible for at least 2-3 months
⇒have to tolerate early side effects for a long time
Can cause menstrual disturbance
? Risk of hypo-oestrogenism
Delay in return of fertility
Weight gain (↑appetite +? Anabolic effect)
↑ prolactin and galactorrhoea
Acne (surprisingly uncommon, mildly androgenic effects)
Enuresis
Subjective effects(loss of libido, depression,
bloatedness, headache, leg cramps)

34. Implant and Injectables
 Menstrual bleeding patterns are highly
variable among users of implant
contraception.Some will experience
increased flow/bleeding days
 Depo-Provera can be used to treat
menorrhagia if regularity of the cycle is
not a concern.

35. Barrier Methods
 Condom useful – no adverse effects on
pre-existing disease (limited by poor
compliance and high failure rate)
 Protective against STDs
 The diaphragm,Femidom and spermicides
are alternatives (high failure rate)
 Less protective against STDs

37. General Medical Disorders











Congenital/Valvular Heart Disease
Venous Thrombo-embolism
Arterial Heart Disease
Stroke
Migraine
Opthalmic Disorder
Hypertension
Diebetes mellitus
Epilepsy
Depression
Smoking

38. Valvular/congenital Heart
Disease
Valvular/Congenital Heart Disease is the leading medical cause
of maternal mortality in Malaysia
It complicates 1 to 4% of all Obstetric admissions
Contraception is all important in management:- from the general health point of view
-family should be small and completed early
-space between pregnancies will allow for
definitive treatment.
-There are conditions where pregnancy may
be contraindicated.

39. IUCD and Valvular/Congenital
Heart disease
 In patients with valvular and congenital heart
disease IUCD use is limited by the risk of
bacterial endocarditis
 The IUCD may be used when other options are
restricted
 -- insertion under antibiotic cover
 Absolute contraindications in those with prosthetic
valve and those with a past history of endocarditis
 Injectables and Implants are safe methods
 COCP contraindicated in valvular/congenital heart
disease

40. For completed family or
pregnancy contraindicated
 Surgical method is ideal
 Vasectomy rather than tubal ligation
 Interval Ligation is preferred to
immediately post-partum
 Minilaparotomy is ideal but laporoscopy in
selected cases

41. COC Pill and Venous
Thrombosis
 Oestrogen increases the production of
clotting factors
 Progestogens have no significant impact
on clotting factors
 All low dose COCPs have an increased
risk of venous thromboembolism
 Smoking has no effect on the risk of
venous thrombosis

42. Factor V Leiden mutation




Produces changes in structure of factor V
Normally protein C inhibits clotting at level of factor V
In Factor V Leiden mutation, this does not happen
The entire clotting cascade is then resistant to the Protein C system
--------------------------------------------------------------- The most common inherited form of venous thrombosis
 Heterozygotes for Factor V Leiden mutation- x8 ↑ risk of thrombosis
 Homozygotes for Factor V Leiden mutation- x80↑ risk of thrombosis
 Highest prevalence of Factor V Leiden mutation is in Europeans(34%)
 Very rare in Africans/Asians (0.4%)

43. Clotting mechanism
Fibrinolysins
Protein C
Protein S
Antithrombins
Plasmin
Prothrombin
Antithrombins
Protein C & S
Thrombin
Factor V +
other clotting
factors
Plasminogen
Fibrinogen
Fibrin ← Plasmin

44. 3rd.generation progestogens and D.V.T.s
 Less androgenic than the older progestogens with a
lesser adverse effect onserum lipids
 Women on 3rd. Generation progesterones have a
higher circulating conc. of HDL and lower conc. of
LDL
 Considered therefore that risk of MI and Stroke
would be lower – but not possible to prove
 BUT – 3 studies(95/96) suggested a x2-3 increased
risk of venous TE with pills containing gestodene
or desogestrol compared with levonogestrel or
norethisterone
 CSM advised – all women at increased risk of
thrombosis(BMI>30),VVs,FH of DVT,PIH,should
change to a 2nd.generation pill

45. Relative risk and actual
incidence of VTE
Population
Relative risk
Incidence
Young femalegeneral population
Pregnant
High dose OC
Low dose OC
Leiden mutation
carrier
Leiden carrier +
OC
Leiden mutation
homogenous
1
4.5/100,000
12
6-10
3-4
6-8
48-60
24-50
12-20
24-40
30
120-150
80
320-400

46. COCP Contraception and
Surgery
 X4to6 fold increased risk of thromboembolic
complications in users of COCP
 COCP should be discontinued at least 4 weeks
before major surgery or prolonged immobilisation
 Can be recommenced on the first day of the next
period but at least 14 days after the operation
 No need to discontinue for minor
surgery/laparoscopy
 No need to discontinue if taking POP/other
progesterone preparation

48. Ischaemic Heart Disease and
COCP
 Oestrogen increases the production of clotting
factors
 Progestogens have no significant impact on
clotting factors
 Past users of OC do not have an increase
incidence of CV disease
 POP pill has a negligible impact on lipoprotein
profile - no increase risk of venous or arterial
thrombosis
 Avoid if hypercholesterolaemia

49. Arterial thrombosis and the
COCP
 Smoking and oestrogen have an addictive effect on the
risk for arterial thrombosis
 Hypertension is a very important additive risk factor for
stroke in the COCP patient
 Almost all M.I. and strokes in OC users occur with high
dose products or users with cardiovascular risk factors
and more than 35 years old.
 Arterial thrombosis has a dose- response relationship with
oestrogen but insufficient data to determine whether there
is a risk difference with 20, 30 or 35µg ethinyl oestradiol

50. Incidence of M.I. In
reproductive age women
< 35 years old
Overall increased
Non- smokers
Non- smokers +
OC
Smokers
Non- smokers +
OC
5/100000/year
4
4
8
43
> 35 years old
Non- smokers
Non- smokers +
OC
Smokers
Smokers + OC
16
40
88
485

51. Contraception and Ischaemic
Heart Disease
– COCP best avoided
– Patients on anticoagulants should not be on
COCP
– IUCD is an excellent form of contraception
– (LNG-IUS ---- very useful)

52. In Ischaemic Heart Disease
 Use alternative contraception to the
COCP:
- IUCD/IUS

- Barrier method

- Implant – may be used in heavy
smokers

- those older than 35yrs.

- hypertensives

- hypercholesterolaemia

53.  Injectables and Implants are safe method
fir those with heart disease
 Antibiotic cover for the implants may be
necessary
 Failure rates are low(PI 0-1.0) and these
methods provide long periods of
contraception

54. Incidence of stroke in
reproductive age women
Incidence of ischaemic
stroke
Haemorrhagic stroke
Excess cases/year
~OCs including
Smokers & HPT
5/100,000/year
1-3 under 35
10 over 35
6/100,000/ year
2/100,000/year in low dose
OC users
1/100,000/year in low dose
OC users <35
8/100,000/year in high dose
users

55. Migraine Sufferers
 Increased risk of ischaemic stroke in
COCP users
 Especially - with other arterial risk factors

- focal neurological symptoms
(asymetrical)

56. Risk of Thrombotic stroke in
Migraine




Background risk for women aged 20 – 2/100,000
Migraine>once a month + COCP - 10/100,000
------------------------Background risk for women aged 40 –
20/100,000
 Migraine >once a month - 56/100,000
 Migraine > once a month + COCP - 100/100,000

57. COCP contra-indicated in the
following groups of patients
 Migraine with aura during which there are
focal neurological symptoms
 Status Migrainosis>72 hours
 All migraines treated with ergot
deriveratives
 Moderately severe migraine without auras
but with other additional arterial risk
factors

58.  Stop the COCP
 Consider --- the POP
--- Implant/Injection
--- IUCD/LNG-IUS

59. Opthalmic Disorders and the
COCP
 Occasional eye discomfort with contact
lenses
---------------------------------- Loss of vision: Retinal artery/vein thrombosis
 Transient cerebral ischaemia
 Benign intracranial hypertension

60. Elevated BP and COC
 ↑ BP reported in some on COCP- occasionally
within a few months of use
 Age is strongly correlated with ↑ BP in COCP
users
 Women with previous HPT in pregnancy may be
more likely to develop ↑ BP on COCP
 ↑ BP that developes on COCP usually returns to
normal after stopping
 Women < 35, otherwise healthy and with BP
well controlled can be prescribed the lowest
oestrogen dose medication under close
supervision
 In any patient BP rises markedly stop

61. Diabetes Mellitus
– Arterial Disease is a major hazard for diabetics
– Avoid Oestrogen with its thrombotic risks
– POP can be a method of choice
– Alternatively – Implant
–
–
–
–
- Injection
- IUCD/IUS
- Barrier method
- Sterilisation

62. Possible Use of COCP in
Diabetes Mellitus
 Young <25 : recent DM
 Free of any complications – arteries, nerves,
kidneys, retina.
 Non smoker, normotensive, BMI<30
 Perceived to need maximum protection against
pregnancy
 No satisfactory alternative
------------------------------------------ Can use an ultra-low COCP using only a lipid
friendly progestogen –mercilon with only 20ug.
Oestrogen
 But COCP for the shortest possible time
 Encourage family as soon as circs. Permit

63. Epilepsy and Contraception
 Effectiveness of hormonal contraception is reduced
in women on anticonvulsants which are liver
enzyme-inducers
 (phenobarbitone, phenotoin,
 carbamezapine, primidone)
 Sodium valproate,
lamotrigine,vigabatrine,benzodiazepine, do not
have this effect.
 Liver enzyme inducing drugs also increase the
metabolism of progestogens and double the usual
dose may be required

64. Epilepsy and contraception
 If hormonal contraception: COCP ----------- 50ugEO should be used with a
reduced pill free interval
 POP ----------- Only to be used if no other
acceptable method
 Depot Provera – Reduce dosing interval
 From 12 to 10 weeks

------------------------------- Alternative non hormonal methods are better
used

65. Depression
 Patients with a history of emotional disturbance
may be prone to depression on the OC
 If severe – change to alternative form of
contraception
 Women with PMS may have a varying response
to OC – ranging from symptomatic improvement
to a worsening of the condition

66. Smoking
 Smoking produces a shift to
hypercoaguability
 A former smoker must have stopped for at
least one year to be regarded as a non
smoker
 Women who have nicotine obtained from
patches or gum in their blood stream
should be regarded as smokers

67. Abdominal pain and COC use
 Thrombosis of major intra-abdominal
vessels
 Gallstones
 Pancreatitis
 Liver adenoma
 Chron’s disease
 Acute porphyria

69. Gynaecological Problems
 Gestational Trophoblastic Disease
 Ectopic Pregnancy
 Menorrhagia
 Endometriosis
 Fibroids
 Pelvic Infection

70. Gestational Trophoblastic
Disease and Contraception
 No evidence of Increased risk in GTD by previous
COCP use
 Close monitoring is required after hydatidiform mole
by serial hCG levels
 Must avoid pregnancy until after 6 months of normal
levels
(may mask a rise in hCG due to malignancy)
 Must not take COCP until after hCG levels have
returned to normal
 (prolongs high hCG status
 increases risk of requiring chemotherapy after HM)

71. COCP and menorrhagia
 Low dose pills are as effective as high in
reducing menstrual flow
 COCP can be used to treat menorrhagia
a/w DUB among teenage and
perimenopausal groups
 COCP used to treat menorrhagia reduces
menstrual blood flow by 50%

72. IUCD and menorrhagia
 Inert and copper IUCD a/w increase in
menstrual blood loss (55% ↑ with copper
IUCD)
 But menstrual blood loss ↓ if device
impregnated with progestogen
 LNG-IUS- 20% amenorrhoeic after 1 year
 Menorrhagia a/w inert/ copper IUCD can
be treated with NSAIDs

73. Endometriosis
 The use of COCP is a/w a lower incidence of
endometriosis
 The protective effect is probably limited to
current or recent use
 Consistent with the belief that hormonal
treatment of endometriosis should be viewed as
suppressive not curative
 Use progestogen dominant COCP on a‘tricyclic’
regime

74. Uterine fibroids
 Uterine fibroids are not a contraindication for low dose
COCP
 There is evidence that the risk of fibroids is decreased by 1/3
in women who used higher dose of COCP for 10 years
 Case controlled studies with lower dose have found neither a
decrease nor an increase in risk although Nurses Health
Study reported a slightly increased risk when COCP was
used in early teenage
 The administration of low dose COCP to women with fibroid
does not stimulate fibroid growth
 COCP is a/w reduction in menstrual bleeding

75. COCP and Pelvic infection
 Pelvic Inflammatory Disease usually a consequence
of STD
 The risk of hospitalisation for PID is reduced by about
50-60% in COCP users - but at least 12 months of use
are necessary & protection is limited to current users
 If the patient does get pelvic infection, the severity of
salphingitis found at laparoscopy is reduced
(gonococcus)

76. COCP and Pelvic infection
 The mechanism of protection is unknown:
 ? Thickening of cervical mucous to prevent movement of
pathogens and bacteria laden sperm in uterus and tube
 ↓menstrual bleeding ↓ movement of pathogens into tubes
 ↓ in culture medium
 But suggested that chlamydial infection may be
enhanced- 15 of 17 studies showed an association
of COCP and chlamydial cervicitis (? Due to
ectropion)
 But COCP users are protected against
symptomatic PID and there is no evidence for ↑
tubal infertility

77. Examination and follow- up
 Thorough history and
examination
 BP
 Breasts
 Liver
 Extremities
 Pelvic organs
 Cervical smear
Follow- up visits
 First 3 months after
OC
 Thereafter yearly if no
risk factors
 If risk factorssee 36 monthly by trained
personnel

79. Blood tests







Glucose, lipid and
lipoproteins
Young women at least
once
Women > 35 years old
Strong family history of
heart disease, HPT, DM
History of gestational
DM
Zanthomatosis
Obese women
Diabetic women
Coagulation screen
 Personal/family history in
young first degree
relative of idiopathic
thrombophilia
 Check for:
Antithrombin III
deficiency
Protein C deficiency
Protein S deficiency
Factor V Leiden mutation
Prothrombin gene
mutation
Antiphospholipid
syndrome

80. Consider whether the medical
condition would : Increase the risk of venous thromboembolism
 Predispose to arterial wall disease
 Adversely affect liver function
 Be influenced by sex hormones
 Require treatment with an enzyme
inducing drug
 Risk of exacerbating pelvic sepsis

81. Remember

DIMS

BNF