Presented by:

DR.NAFISA BADAWI ELTAYEB

OBSTETRICIAN AND GYNAECOLOGIST
Clinical MD
SMSB
Correct and consistent use of effective
methods of contraception can prevent most
unintended pregnancies.
 Abortion is a major consequence of
unintended pregnancy, and in many low- and
middle income countries, abortions are often
performed under unsafe conditions and result
in women dying or suffering serious injuries.
Approach to lady wish to use contraception
Her wish to conceive.
Reversibility of contraceptive method.
Mehtods acceptable to her.(hormones, others)
Any contraindication.
Period of contraception (months, 3-5 years, 10 years)
Always discuss risk of STIs.
Offer information leaflet.
Give her time to decide.
History:
Age

Previous contraception(any complications)

 past-obstetric history, current lactation.
Menstrual history.
STIs.

PMH (DM, HTN, IHD, TED, liver disease, migraine, breast

cancer.)
Allergies.

 DH (anti-epileptic drugs, antibiotics)

Smoking, cervical smear history.
 FH (TED, cardiovascular disease in 1st degree relative).
Examination
BMI

BP
MEC (medical eligibility criteria)
Most women who use contraception are fit and healthy.
However, some health conditions may be associated with real
or theoretical risks, (WHO) developed a system addressing
medical eligibility criteria for contraceptive use.
Category 1: A condition for which there is no restriction for
the use of the contraceptive method.
Category 2: A condition where the advantages of the method
generally outweigh the theoretical or proven risks.
Category 3: condition where the theoretical or proven risks
generally outweigh the advantages of using the method.
Category 4 : A condition that represents an unacceptable
health risk if the contraceptive method is used.
What a woman needs to know before starting a method of
contraception?
How to use the method (pill, patch or ring) and what to do
when misused (e.g. missed pill)
 Failure rates
 Common side-effects
 Health benefits
 Fertility return on stopping
 When she need review?
 Combined hormonal contraception
 Methods contain two hormones: an oestrogen and a
progestogen.
 They are available as oral pills, a transdermal patch and as a
vaginal ring.
Mechanism of action:
1. Work by inhibition of ovulation via negative feedback of
oestrogen and progestogen on the pituitary, with suppression
of follicle-stimulating hormone (FSH) and luteinizing
hormone (LH).
2. Thickening of cervical mucous to prevent sperm penetration.
3. Thinning of endometrium to prevent implantation.
 Most of the commonly used COCPs are ‘low dose’ and contain
ethinyl oestradiol in a dose of 15–35 μg.
Failure rate about 0.1% correct use.
 Absolute contraindication to COCPs:
1. Previous thrombosis
2. Ischemic heart disease
3. Cardiomyopathies
4. Smoking and age >35.
5. BMI > 40
6. BP >160/100
7. Severe diabetes mellitus
8. Focal migraine
9. Thrombophilia
10. 4 weeks before major surgery – 2 weeks after full mobility
11. Active liver disease
12. Severe inflammatory bowel disease
13. Undiagnosed genital tract bleeding / pregnancy.
14. Acute porphyria / SLE
15. Uncorrected valvular heart disease
16. TIAs / cerebral haemorrhage
17. Trophoblastic disease – until HCG undetectable.
18.Breastfeeding and <6 weeks postpartum.
19.Breast cancer.
Risk of VTE :
 Healthy woman not taking COCP - 5 / 100,000
 Second generation COCP user - 15 / 100,000
 Third generation COCP user (desogestrel or gestodene) 25
/ 100,000
 Pregnancy - 60 / 100,000
Non contraceptive uses of COCPs:
 Dysmenorrhea.
 Dysfunctional Uterine Bleeding
 Anaemia.
 Heavy menstrual bleeding
 Irregular menses
 Hirsutism, Acne.
 Premenstrual syndrome
 Reduces risk of ovarian cancer, endometrial cancer, colorectal cancer.
 Benign breast conditions. .
 Functional ovarian cysts
 Ectopic pregnancy.
Missed pills:
If you have missed one pill, anywhere in the pack:
Take the last pill you missed now.
Continue taking the rest of the pack as usual.
If you have missed 2 or more:
In the 1st week
Take the missed pill, use condoms for next 7 days.
Ifunprotected intercourse emergency contraception should be
used.
In the 2nd week
Take the missed pill, use condoms for next 7 days.
In the last week
Omit the pill free interval, start new packet + condom for 7
days.
When to start taking pills?
From day 1-5 of the cycle.
Side effects:
Unscheduled bleeding and spotting.
Weight gain.
Breast tenderness and bloating.
Depression and loss of libido.
Hair loss, headache.
Cervical ectropion.
Progestogen-only contraceptive methods:
Progestogen-only methods are available as pills, injectable,
implant and intrauterine system.
mechanism of action of the method and the bleeding pattern
appear to depend on the dose of progestogen and also the route
of administration.
Progestogen-only pill (POP)
Acting by thickening of cervical mucous so prevent sperm
penetration.
Side-effects of all POPs include
possible irregular bleeding, persistent ovarian follicles (simple
cysts) and acne.
Window period is 3 hours.
 Extra precautions (condoms) for the next 48 hours until the
progestogen effect on the mucus is built up.
Ifunprotected sex occurs during this time, then emergency
contraception is required.
 Implants
containing the progestogen etonorgestrel 68mg.
 Is a flexible rod, similar in size to a match stick and is
inserted subdermally 8 cm above the medical epicondyle,
usually of the non-dominant arm.
Insertion is conducted under local anaesthesia.
Duration 3 years.
Act by inhibit ovulation.
Can be used with breastfeeding .
Used in cases of menorrhagia and dysmenorrhea.
Cause amenorrhea.
Immediate return of fertility after removal.
Can be used in cases of ectopic.
SE: spotting and irregular vaginal bleeding.
 Injections
Themost commonly used is a depot injection of
medroxyprogesterone acetate.
whichcan be administered intramuscularly as the formulation
Depoprovera (150 mg).
injection interval (every 12–14 weeks).
The injection is the only hormonal method that may delay
return of fertility after discontinuation, in some cases it may
take up to 1 year after the last injection for ovulation to return.
Cause amenorrhea up to one year.
Reduce bone mineral density.
 weight gain.
 Progestogen-releasing intrauterine system
The currently available intrauterine systems 52 mg LNG-IUS
(Mirena), levonorgestreal
Is licensed for 5 years for contraceptive use.
The LNG-IUS works by exerting a potent hormonal effect on
the endometrium, which prevents endometrial proliferation and
implantation. Its progestogenic effect on thickening the
cervical mucus also impedes entry of sperm.
NON-CONTRACEPTIVE USES
1- menorrhagia - up to 97%.
2-dysmenorrhoea.
3-PMS, HRT
4-low rate of ectopic pregnancy .
5-protection against PID.
6-management of endometrial hyperplasia.
SIDE-EFFECTS
 Difficulties with insertion – especially in nulliparous
women.
Irregular bleeding.
Increased incidence of functional ovarian cysts.
Amenorrhoea.
Progestogenic side effects ( oedema / headache / breast
tenderness / acne )
Expulsion
 copper intrauterine device Cu-IUD
Last 3-10 years.
Act by causing inflammatory reaction in the uterus, the
concentration of macrophages and leucocytes,
prostaglandins and various enzymes in both uterine and
tubal fluid increase significantly.
These effects are toxic to both sperm and egg and
interfere with sperm transport, and implantation is
inhibited.
Insertion of IUD
An IUD can be fitted at any point in the cycle provided
there is no risk of pregnancy.
Risk of perforation.
Risk of expulsion.
Infection.

Missing threads.
 Barrier contraception
Condoms
 Male condoms are cheap and widely available.
 They protect against STIs including HIV.
 The female condom is a lubricated condom that is inserted into the
vagina.
 It also protects against STIs.
Diaphragm and cap
 These are latex or non-latex devices that are inserted into the
vagina to prevent passage of sperm to the cervix.
 Female sterilization
 This is a permanent method of contraception that prevents sperm
reaching the oocyte in the Fallopian tube.
 It can be performed by (1) laparoscopy, (2) hysteroscopy or (3)
laparotomy ( at caesarean section).
 Advice to women considering sterilization
 Method is considered as irreversible.
 Failure rate 1:200 for laparoscopic.
 Risks and complications (laparoscopic 1:1,000 risk of trauma to
bowel, bladder or blood vessels).

Vasectomy is safer, quicker, safer and with less morbidity.
High proportion of women regret sterilization.
Risk factors are age under 30 years, nulliparity, recent
pregnancy (birth, abortion, miscarriage) and relational issues.
Does not protect against STIs.
Risk of ectopic.
 Vasectomy
 This is the technique of interrupting the vas deferens to provide
permanent occlusion.
 Involves a puncture wound in the skin of the scrotum under local
anaesthesia to access and then divide and occlude the vas using
cautery.
 Post-vasectomy semen analysis should be conducted at 12 weeks to
confirm the absence of spermatozoa in the ejaculate.
 Alternative contraception should be used until azoospermia is
confirmed.
 The failure rate is significantly less than female sterilization at
approximately 1 in 2,000.
 Lactational amenorrhoea
If a mother is within the first 6 months postpartum, is
amenorrhoeic and is fully or nearly fully breastfeeding, then the
risk of pregnancy is about 2%.
After 6 months, or if menses occur or breastfeeding reduced,
then another method of contraception must be used.
 Emergency contraception
 The most effective method of EC is an IUD (about 99%
effective).
 An IUD can be inserted up to 5 days after ovulation for EC.
 Ulipristal acetate (UPA) or levonorgestrel (LNG) are available
as oral methods of EC.
 UPA can be given within 120 hours of unprotected intercourse.
 LNG can be used within 96 hours of unprotected intercourse.
 Effective ongoing contraception should be started after EC.