Gynecology 5th year, 1st & 2nd lectures (Dr. Muhabat Salih Saeid)

Contraception

Dr.Muhabat Salih Saeid MRCOG

Learning Objectives Recognize common adverse effects

of estrogen and progestin In a patient case be able to provide

a recommendation for symptom management

Identify contraindications to contraceptive options

Contraception Definition Contraception generally implies the

prevention of pregnancy following sexual intercourse by inhibiting viable sperm from coming

into contact with a mature ovum by preventing a fertilized ovum from

successfully implanting in the endometrium.

Commonly used methods Reversible contraception

Oral contraceptives Long acting injectable or implantable

progestins Combined estrogen patch Condoms, spermicides, diaphragms,

withdrawal, periodic abstinence, and IUD’s

Properties of Contraceptive Desired by Patients Highly effective Prolonged duration of action Rapidly reversible Privacy of Use Protection against STD’s Easily accessible

Oral Contraceptives Introduced to the US in 1960 Works through the manipulation of

normal physiologic feedback mechanisms of the menstrual cycle by varying amounts of estrogen and/or progestin.

Proven to be a very effective and popular method of birth control.

The Pill

Advantages Easy to use Dependable No additional appliances Can regulate menstrual flow and

decrease cramps and other symptoms of menses

Missed pills Missed 1 day:ASAP and next pill

at regular time Missed 2 days: 2 when she

remembers, 2 the next day, use back up until her next period

More than 2 days: Restart and use a back up method

Contraindications History of cerebrovascular disease Uncontrolled hypertension DVT or PE Migraines worsened by estrogen Estrogen dependent neoplasm Ischemic heart disease IDDM w/ complications Breast Cancer Impaired liver function Smokers>35y/o

Estrogen Inhibits ovulation by suppressing of

pituitary release of FSH/LH (negative feedback)

Inhibits implantation by altering secretions within the uterus

Accelerates ovum transport Induction of luteolysis: degeneration of

corpus luteum prevents normal implantation and placental attachment

Estrogenic Side Effects Nausea Weight gain Fluid retention Pulmonary emboli Hypertension Thromboembolic complications Stroke Increase in bile cholesterol

Progesterone Inhibits ovulation by disruption of

HPO function and by modification of mid-cycle FSH/LH surge

Inhibits implantation by suppressing the endometrium

Production of thick cervical mucus Prevention of sperm penetration Slows ovum transport

Progestin Side Effects Increased appetite Depression, fatigue, lethargy Acne, oily skin Hirsutism Headache Weight gain Decreased libido Increased LDL, decreased HDL Hypertension

Noncontraceptive benefits Relief from

menstruation-related problems Decreased cramps Decreased

ovulatory pain Decreased

menstrual blood loss

Disease prevention Ovarian and

endometrial cancer Ovarian cysts Ectopic pregnancy Pelvic inflammatory

disease Benign breast

disease

Contraindications History of cerebrovascular disease Uncontrolled hypertension DVT or PE Migraines worsened by estrogen Estrogen dependent neoplasm Ischemic heart disease IDDM w/ complications Breast Cancer Impaired liver function Smokers>35y/o

Transdermal Contraception Ortho Evra

Norelgestromin and Ethinyl Estradiol

Similar to OC’s

Not recommended in patients >198lbs, less effective

Applied every 7 days for 3 weeks followed by patch free week

Convenience, increased compliance

Ortho Evra If a patch comes

off???? <24 hours

Reapply use a new patch

>24 hours apply a new patch use this day as the new

patch change day use a back up method

until 7 consecutive days

Patient Education Similar side effects to

OC’s Same incidence of

drug interactions Apply to abdomen,

buttock, upper outer arm, and upper torso

Back up method should be used until after the first 7 days of consecutive administration

Implants Progestin only (Norplant) Prevents ovulation More effective than the Pill

Implant Advantages

Convenience Eliminate user error No menses or very light Decreased cramping

Implant Problems

• Difficulty in removing

Side effects•Similar to the

pill•Changes in

menstrual bleeding

•Headaches

Side effects•wt. gain•Acne•breast

tenderness•hair growth•ovarian cysts

Implant Contraindications

Liver disease Breast cancer Cardiovascular disease Unexplained vaginal bleeding Pregnant Smokers

Injectable Contraceptives Depo-Provera

Medroxyprogesterone acetate 150mg/ml Progestin only

Inhibits ovulation for 3 months

IM injection 5 days w/in onset of menstrual bleeding and Q12 weeks

Depo-Provera Advantages Highly effective

99.7% Increased compliance Amennorrhea

Reduced risk of anemia Decreased menstrual

cramps/pain No drug interactions

w/ anticonvulsants

Disadvantages Break through

bleeding Weight gain Headache Depression Decreased HDL Risk of ectopic

pregnancy Contraception

reversible in 4-13months

Barrier Methods

The condom Female condom Diaphragm Cervical cap Sponge

IUD Intrauterine device Copper and plastic (Copper T-380A)

10 years Plastic and Progesterone

(progestasert IUD) 1 year 90-96 % effective in use Increased risk of PID

Spermicides Nonoxynol-9 Use in combination with barrier

methods of contraception Foam gel Film Creams, jellies and suppositories

Fertility Awareness Methods Calendar or rhythm method

Midway in cycle Basal body temperature (BBT) method

Increase in body temperature Cervical Mucous Method

Clear slippery mucous Symptothermal method

Combination of BBT and Cervical Mucous methods

Sterilization For Women

Tubal ligations• Cut and seal the fallopian tubes

Hysterectomy• Removal of the uterus

For Men Vasectomy

Vas deferens are cut and sealed

Emergency Contraception Emergency Contraception Pill (ECP) Copper IUD

Emergency Contraception Indications: Unprotected

intercourse Condom

slipped/broke Missed pills

Sexual assault

Preven 50µg EE and

0.25mg levonorgestrel

Plan B 0.75mg

levonorgestrel

Patient Education Prescribing Info. First dose must be

taken within 72 hours of unprotected intercourse

Second dose is 12 hours later

Side Effects Nausea Vomiting Breast Tenderness

Reglan(metoclopramide) 1 hour prior can reduce n/v

Repeat dose if vomiting occurs w/in 1 hr of admin.

Abortion Spontaneous abortion (miscarriages) Induced abortion

Injectable Contraceptives Depo-Provera

Medroxyprogesterone acetate 150mg/ml Progestin only

Inhibits ovulation for 3 months

IM injection 5 days w/in onset of menstrual bleeding and Q12 weeks

Depo-Provera Advantages Highly effective

99.7% Increased compliance Amennorrhea

Reduced risk of anemia Decreased menstrual

cramps/pain No drug interactions

w/ anticonvulsants

Disadvantages Break through

bleeding Weight gain Headache Depression Decreased HDL Risk of ectopic

pregnancy Contraception

reversible in 4-13months

Implantable Contraception Norplant Subdermal progestin implant 6 implantable capsules filled

w/ levonorgestrol Requires physician

administration Effective for 5 years Every 3 yrs for women

weighing >154lbs

Norplant Advantages Convenience Highly effective Decreased

menstrual cramps Fertility rapidly

returns

Disadvantages Irregular period Headache Depression Weight gain Pain/itching @ site Site infection Ectopic pregnancy Removal difficulties

TTTTT