Contraception

Dr Chaambwa H
Obstetrician and Gynaecologist
September 2017
 Methods of Contraception

 Contraception is the prevention of conception by methods other than

abstinence.
 It is used to limit the size or space the family

(birth control)
or
(Family planning)

Dr Chaambwa H, OBGY
 Ideal Contraception
An ideal contraception should fulfill the following:
 Highly efficient
 Free from unwanted side effect
 Absolute safety
 Independent of intercourse
 Simplicity of use
 Reversible
 Well tolerated

Dr Chaambwa H, OBGY
Methods of Contraception

The following is an overview of the currently available methods of

contraception:

Dr Chaambwa H, OBGY
 Barrier Methods
 Have been the most widely used contraceptive
technique throughout recorded history.
 The condom –male and female
 Diaphragms and cervical caps
 sponge
 Spermicides

Dr Chaambwa H, OBGY
Hormonal Methods

 Combined
 Combined Oral contraceptive pills
 Combined hormonal patches
 Combined vaginal rings
 Progestogen only preparations
 Progestogen only pills
 Injectable contraceptives
 Subdermal Implants

Dr Chaambwa H, OBGY
Intrauterine contraception

 Copper intrauterine contraceptive device (IUCD)

 Hormone releasing intrauterine system

Dr Chaambwa H, OBGY
Sterilization

 Vasectomy
 Female sterilization

Dr Chaambwa H, OBGY
Natural family planning

 Coitus interruptus
 Fertility awareness methods
 Billings (cervical mucus)
 Basal body temp
 Calender
 Lactational amenorrhoea

Dr Chaambwa H, OBGY
Efficacy of contraceptive methods

 Virtually all methods occasionally fail.

 Some are much more effective than others
 Pearl index(failure rate): is expressed as the number of failure per
100women years(HWY). That is the number of pregnancies occurring if 100
women were to use a method for 1 year

Dr Chaambwa H, OBGY
 Contraceptive method Failure rate per 100 women-years

Perfect use Typical use

Combined oral contraceptive pill 0.1 3
Progestogen -only pill 1.1 9.6
Depo-Provera 0.1 2
Implant 0.05 0.05
Copper-bearing IUD 0.8 3
Levonorgestrel-releasing IUD 0.5 0.5
Male condom 2-5 15
Female diaphragm 5 16
Female condom 21 21
Natural family planning 2-3 28
Vasectomy 0.02 0.15
Female sterilization 0.13 0.5
LAM 2
No method
Dr Chaambwa H, OBGY 85
 Barrier Methods
The condom
 Simple
 Effective methods of contraception- 85 to 98% success rate
 Without side effects
 Available
 Reduce the risk of STIs, HIV and cervical neoplasia

Dr Chaambwa H, OBGY
Diaphragms and Cervical Caps and The
Sponge
 The diaphragms and cervical caps should be used with spermicide
 Failure rate 5-16 %
 The sponge is known in the U.K and the USA
 Advantage of the sponge in that it can be left for 24 hours in the vagina
,besides that one size fits all women

Dr Chaambwa H, OBGY
Diaphragm

Dr Chaambwa H, OBGY
Spermicides

 In the form of creams, gel aerosols, melting suppositories and foaming

tablets
 Used alone
 Failure rate 10- 15 %

Dr Chaambwa H, OBGY
Hormonal Methods
 Oral contraception
Two types:
 Combined oral contraceptive pill: most commonly used ( combination
of estrogen and progestogen) e.g
 Microgynon
 Safeplan
 oralconF
 Progestogen only pill : mini pill
e.g
 Microlut

Dr Chaambwa H, OBGY
Combined oral contraceptives (COCs)

 Consists of oestrogen (E) and progestin (P)

 Monophasic pills - same dose of E/P all through the course
 Biphasic pills - fixed dose or E/P & more P in the last 14/7
 Triphasic pills - variable dose of E/P
 Sequential pills - fixed dose of E, No P for first 7/7 then P for 14/7
 Note that biphasic, triphasic and sequential pills are not in common use

Dr Chaambwa H, OBGY
Combined oral contraceptives
Mechanism of action
 Prevents ovulation by inhibiting gonadotrophin secretion via an effect on both
pituitary and hypothalamic centres
 The progestin suppresses LH secretion (& thus prevents ovulation, while the
oestrogenic agent suppresses FSH secretion (& thus prevents the selection and
emergence of a dominant follicle

Dr Chaambwa H, OBGY
Efficacy of COC

 Typical usage is associated with a 3.0% failure rate during the first year of use

 Efficacy decreases significantly when the oestrogen component is removed

Dr Chaambwa H, OBGY
Absolute contraindications to COC use

 Thrombophlebitis, thromboembolic  Undiagnosed abnormal vaginal

disorders, CVA, coronary occlusion bleeding
 Markedly impaired liver function  known or suspected pregnancy
 Known or suspected breast cancer  Smokers over the age of 35 years

Dr Chaambwa H, OBGY
Relative contraindications to COC use

 Migraine headaches  H/O obstructive jaundice in

 pregnancy
Hypertension
 Sickle cell disease or sickle C
 H/O gestational diabetes
disease
 Elective surgery  Diabetes mellitus
 Epilepsy  Gall bladder disease

Dr Chaambwa H, OBGY
Clinical problems associated with COCs

 Breakthrough bleeding  Drugs that affect efficacy

 Amenorrhoea  Migraine headaches
 weight gain
 Acne; rarely

Dr Chaambwa H, OBGY
Drug interaction

Effect of other drugs Effect of COCs

on COC
 Enzyme inducing drugs e.g. (a) barbiturates
(b) all antiepileptic drugs except sodium
on ther drugs
valproate and clonazepam (c) rifampicin (d)  Effectiveness of some drugs
ketoconazole (e) griseofulvin (f) ritonavir (g) (Aspirin, oral anticoagulants, oral
nevirapine
hypoglycaemics) are decreased
 Some broad spectrum antibiotics amoxicillin,
tetracycline, doxycycline — as they impair  and that for some other drugs
the absorption of ethinyl estradiol (beta blockers, corticosteroids,
 under such circumstances high dose diazepam, aminophylline) are
preparations (ethinyl estradiol of 50 µg or increased by oral contraceptives.
more) are to be used or barrier method is
employed.
Dr Chaambwa H, OBGY
Non-Contraceptive Benefits of OCs

These can broadly be grouped into two main categories:

 Benefits that incidentally accrue when COCs is specifically utilized for
contraception &;
 Benefits that result from the use of COCs to treat problems or disorders

Dr Chaambwa H, OBGY
Non contraceptive incidental benefits of
OCs
 less PID
 less endometrial cancer  less rheumatoid arthritis
 less ovarian cancer  increased bone density
 fewer ectopic  less endometriosis
pregnancies.  less benign breast disease
 more regular menses  fewer ovarian cysts
 Less anaemia

Dr Chaambwa H, OBGY
COCs as treatment

 DUB  hormone therapy for hypothalamic

 amenorrhoea
dysmenorrhoea
 control of bleeding
 mittelschmerz
 premenstrual syndrome
 endometriosis prophylaxis
 acne & hirsutism

Dr Chaambwa H, OBGY
Pill taking

 Effective contraception is present during the first cycle of pill use, provided
the pills are started no later than the 5th day of the cycle and no pills are
missed

Dr Chaambwa H, OBGY
Missed Pills

 If a woman misses 1 or 2 pills, she should take the most recent missed pill as
soon as she remembers. She should continue taking the remaining pills daily
at her usual time. No back-up is needed.
 If she misses 3 or more pills at any time, she should take the most recent
missed pill as soon as she remembers. She should continue taking the
remaining pills daily at her usual time. Back-up is needed for the next 7 days

Dr Chaambwa H, OBGY
Missed pills cont

 In addition, if 3 or more pills are missed in the first week, emergency

contraception should be considered if she had sex.
 If pills are missed in the 3rd week, she should finish the pills in her current
pack and start a new pack the next day, thus omitting the pill free interval

Dr Chaambwa H, OBGY
Combined Oral Contraceptives

Advantages
 These are simple to use and highly effective
 No special preparation is necessary before intercourse
 The pill may relieve irregular menstrual periods, cramps and premenstrual
tension

Dr Chaambwa H, OBGY
The Progestin-Only Pill (POP) Mini pill

 The mini pill contains a small dose of progestogen agent (25% of that in COC)
and must be taken daily, in a continuous fashion

Dr Chaambwa H, OBGY
Mechanism of Action - POP

The contraceptive effect is more dependent upon endometrial and cervical

mucus effects, since the gonadotrophins are not consistently suppressed
 The endometrium involutes and becomes hostile to implantation and the
cervical mucus becomes thick and impermeable

Dr Chaambwa H, OBGY
POP cont’d

 There are no significant metabolic effects (lipid levels, CHO metabolism and
coagulation factors remain unchanged)
 There is an immediate return to fertility upon discontinuation
 Failure rates range form 1.1 to 9.6% per 100 women in the first year of use

Dr Chaambwa H, OBGY
POP cont’d

Pill taking
 The mini pill should be started on the first day of menses and a back-up
method must be used for the first 7 days
 The pill should be taken at the same time of the day
 If more than 3 hours late in taking a pill, a back-up method should be used for
48 hours

Dr Chaambwa H, OBGY
Problems associated with POP

POP have unpredictable effect on  20% total lack of cycles ranging

ovulation from irregular bleeding to spotting
 and amenorrhoea
40% of patients can expect to have
normal ovulatory cycles  development of functional cysts
 40% short irregular cycles  levonorgestrel minipill may be
associated with acne

Dr Chaambwa H, OBGY
POP

There are two situations where excellent efficacy is achieved:

 In lactating women, the contribution of the minipill is combined with
prolactin-induced suppression of ovulation adding up to very effective
protection
 In women over age 40, reduced fecundity adds to the minipill’s effects.

Dr Chaambwa H, OBGY
Implant contraception - NORPLANT

 Progestin circulating at levels 1/4 to 1/10th of those in COC, prevents

conception by suppressing ovulation and thickening cervical mucus to inhibit
sperm penetration
 Side effects include changes in menstrual pattern, weight gain, headache,
and effects on mood

Dr Chaambwa H, OBGY
NORPLANT

 consists of 6 capsules 34mm in  the capsules release ~ 80 micro

length, 2.4 mm outer diameter, grams of levonorgestrel per 24
containing 36 mm crystalline hours during the first 6-12 months
levonorgestrel. of use
 the 6 capsules contain a total of  once inserted have an effective life
216 mg of levonorgestrel which is of 5 years
very stable

Dr Chaambwa H, OBGY
The mechanism of action

 Suppression at both the hypothalamic and pituiatry LH surge necessary for

ovulation
 The constant level of progestin has a marked effect on the cervical mucus
 Suppression of the estradiol-induced cyclic maturation of the endometrium
and eventually causes atrophy

Dr Chaambwa H, OBGY
Disadvantages of NORPLANT

 disruption of bleeding patterns in  implants can be visible under the

up to 80% of users naked eye
 implants must be inserted and  does not protect against STI/HIV
removed in a surgical procedure by  acne
trained personnel

Dr Chaambwa H, OBGY
Absolute contraindications

 active thrombophlebitis or  benign or malignant liver tumours

thromboemboilc phenomena  known or suspected breast cancer
 undiagnosed genital bleeding
 acute liver disease

Dr Chaambwa H, OBGY
IMPLANON

 A single implant 4 cm long contains 60 mg of 3-keto desogestrel

 The hormone is released at a rate of about 60 micro grams per day
 Is designed to provide contraception for 2-3 years
 Efficacy and side effects are similar to those of NORPLANT

Dr Chaambwa H, OBGY
Jadelle

 Two rods containing 75mg LNG crystals embedded in a coplolymer and

encased in silastic tubing
 Rods are 43mm long and 2.5mm wide
 Lasts for 5 years
 Rods are easier and more convenient to insert and remove
 Norplant and Jadelle are bioequivalent over 5 years of use

Dr Chaambwa H, OBGY
Injectable Contraception:
Depo-Provera
 Comes as microcrystals, suspended in an aqueous solution
 Correct dose is depot medroxyprogestrone acetate 150 mg IM (gluteal or
deltoid) every 3 months
 Relies on higher peaks of progestin to inhibit ovulation and thicken cervical
mucus. The progestin level is high enough to block the LH surge

Dr Chaambwa H, OBGY
Depo-Provera
cont’d
 The injection should be given within the first 5 days of the current menstrual
cycle, otherwise a back-up method is necessary for 2 weeks
 The injection must be given deeply in muscle by the Z-track technique and
not massaged

Dr Chaambwa H, OBGY
Depo-Provera
Advantages
 easy to use, no daily or coital  free from estrogen related
acton required problems
 safe no serious health effects  private use not detectable
 effective as sterilization, IUCD &  enhances lactation
implant contraception  has non contraceptive benefits

Dr Chaambwa H, OBGY
Depo-Provera
Disadvantages
 irregular menstrual bleeding  can’t be removed
 breast tenderness  return to fertility is delayed
 weight gain  regular injections required
 depression  no STI/HIV protection

Dr Chaambwa H, OBGY
Depo-Provera
Absolute contraindications

 Pregnancy

 Unexplained genital bleeding

Dr Chaambwa H, OBGY
Injectable Contraception:
Noristerat
 Norethisterone enanthate 200mg
 Given every 2 months
 Similar to Depot provera in all areas

Dr Chaambwa H, OBGY
Intrauterine Contraception

Types of IUDS

 Copper IUDs - TCu-380A

 Hormone-releasing IUDs (LNG-IUS) - mirena

Dr Chaambwa H, OBGY
IUCD
Mechanism of Action
 The mechanism of action is the production of an intrauterine environment
that is spermicidal and interfere with implantation

 Ovulation is not affected nor is the IUCD an abortifacient

 Abortifacient means “causing abortion”

Dr Chaambwa H, OBGY
Efficacy of IUDS

 The actual failure rate in the first year is approximately 3%, with a 10%
expulsion rate, and a 15% rate of removal, mainly for bleeding and pain.
 The non medicated IUDs never have to be replaced

Dr Chaambwa H, OBGY
Timing of IUCD insertion

 An IUCD can be safely inserted at any time; after delivery, abortion or during
the menstrual cycle

 The IUCD can also be inserted at Caesarean section

Dr Chaambwa H, OBGY
IUCD Use
contraindications
 Presence of pelvic infection current or within 3 months;
 Undiagnosed genital tract bleeding;
 Suspected pregnancy;
 Distortion of the shape of the uterine cavity as in fibroid or congenital uterine-malformation;
 Past history of ectopic pregnancy;
 Trophoblastic disease;
 Additionally for CuT380A are: Wilson disease and Copper allergy.

Dr Chaambwa H, OBGY
Pregnancy with IUD in situ

 Spontaneous abortion - 40-50%, IUDs should be removed if pregnancy is

diagnosed and the strings are visible and pregnancy less than 12weeks
 Removal may trigger an abortion, hence it may be justified to leave it
especially if pregnancy is 12 or more weeks of gestation or if strings not
visible.
 Pre-term labour and birth - incidence is increased 4-fold

Dr Chaambwa H, OBGY
Missing strings

 The thread may not be visible through the cervical os due to —

 Thread coiled inside;
 Thread torn through;
 Device expelled outside unnoticed by the patient;
 Device perforated the uterine wall and is lying in the peritoneal cavity;
 Device pulled up by the growing uterus in pregnancy.
 Methods of identification:
 Ultrasonography can detect the IUD either within the uterine cavity or in the
peritoneal cavity (if perforated).

Dr Chaambwa H, OBGY
Natural family planning

 Coitus interruptus
 Fertility awareness methods
 Billings (cervical mucus)
 Basal body temp
 Calendar
 Lactational amenorrhoea

Dr Chaambwa H, OBGY
Coitus interruptus

 Involves removal of the penis from the vagina before ejaculation takes place
 1st year failure rate - 18%
 Some sperm may be released before ejaculation
 Is a better method than using no method at all

Dr Chaambwa H, OBGY
Fertility awareness

 Is keyed to the observation of naturally occurring signs and symptoms of the

fertile phase of the menstrual cycle.
 It takes into account the viability of sperm in the female reproductive tract
and the life span of the ovum

Dr Chaambwa H, OBGY
Methods of fertility awareness

 Rhythm of Calendar method

 Fertile period is calculated
 Cervical Mucus method
 During the fertile period and relative infertility period, the cervical mucus is copious, while during
the absolute infertile period there is no cervical mucus

 Basal body temperature method

 The rise in temp of 0.5 for 3 days indicate luteal phase

Dr Chaambwa H, OBGY
Lactational Amennorrhoea Method (LAM)

 High concentrations of prolactin work at both central and ovarian sites to

produce lactational amenorrhoea and anovulation

 Elevated levels of prolactin inhibit the pulsatile secretion of GnRH

Dr Chaambwa H, OBGY
LAM

 Only amenorrhoeic women who exclusively breastfeed at regular intervals,

including at nighttime, during the first 6 months have the contraceptive
protection equivalent to the provided by oral contraception

Dr Chaambwa H, OBGY
LAM

 With menstruation or after 6 months, the risk of ovulation increases

 Supplemental feeding increases the risk of ovulation (and pregnancy) even in
amenorrheic women

Dr Chaambwa H, OBGY
B/feeding and Contraception

The rule of 3s
 In the presence of FULL b/feeding, a contraceptive method should be used
beginning in the 3rd postpartum month
 With PARTIAL b/feeding or NO b/feeding, a contraceptive method should
begin during the 3rd postpartum week

Dr Chaambwa H, OBGY
B/feeding and Contraception

 Combined Oral contraceptives even in low doses diminishes the quantity and
quality of breast milk

 Progestogen only contraceptives do not affect breast feeding

Dr Chaambwa H, OBGY
Sterilization

 Female and male sterilization are permanent methods of contraception and

are highly effective
 Indicated in clients with satisfied parity or with medical conditions precluding
pregnancy

Dr Chaambwa H, OBGY
Female Sterilization

 Mechanical blockage/ excision of both fallopian tubes

 Can be done laparoscopy, laparotomy, mini-lap
 Timing:
 during caesarean section,
 puerperal, or
 interval

Dr Chaambwa H, OBGY
Male Sterilization

 Excision of the vas deferens to prevent release of sperm during ejaculation

 It is easier quicker and more straightforward than female sterilization
 It is not effective immediately : may take up to 3 to 4 months
 Hence alternate method should be used until azoospermia confirmed.

Dr Chaambwa H, OBGY
Emergency Contraception

 Emergency contraception methods can prevent pregnancy after unprotected

intercourse, method failure or incorrect method use
 Can help reduce unplanned pregnancies, many of which result in unsafe
abortion
 Prescribed within 72 hours of unprotected sex. For IUCD it can be inserted up
to 5days after unprotected sex

Dr Chaambwa H, OBGY
Emergency contraception methods

 Progestin only pills

 Intra uterine contraceptive device

 Combined oral contraceptive pills

Dr Chaambwa H, OBGY
POP

 Single dose 1500mcg of Levonorgestrel

 Two doses of 750mcg Levonorgestrel taken 12hry apart

Dr Chaambwa H, OBGY
POP

 Ovrette - 20 tablets per dose, each tablet contains 0.0375 mg Levonorgestrel

 Microlut, Microval, Norgestron - 25 tablets per dose, each tablet contains
0.03mg Levonorgestrel

Dr Chaambwa H, OBGY
IUCDs

 Copper T

 Insertion within 120 hours (five days) of unprotected intercourse

Dr Chaambwa H, OBGY
Oral contraceptive pills

 Emergency contraceptive pills use the same ingredients as regular

contraceptives
 Should be initiated ideally within 3 days (72 hours) of unprotected intercourse
 Should be taken in two doses 12 hours apart

Dr Chaambwa H, OBGY
COC

 Each of the two doses of COC should contain at least 100 ug (0.10 mg) Ethinyl
Estradiol (EE) and 500 ug (0.50 mg) Levonorgestrel

Dr Chaambwa H, OBGY
COC

PC-4, Eugoynon 50, Neogynon, Noral, Nordiol, Ovidon, Ovral, Ovran

 Two tablets per dose: each tablet contains 50 ug EE & either 0.25mg or 0.50
mg levonorgestrel

Dr Chaambwa H, OBGY
COC

LoFemenal, Microgynon 30, Nordette, Ovral L, Rigevidon

 Four tablets per dose: each tablet contains 30 ug EE & either 0.15 mg or 0.30
mg Levonorgestrel

Dr Chaambwa H, OBGY
Conclusion

 The world population is around 6 billion , four hundred million couples

are practicing a family planning, many couples around the world who are
motivated to practice family planning lack the sources or the methods
suitable for their needs.
 At least one method may be suitable for each couple at any given time in
order to plan their families and avoid unwanted pregnancy.

Dr Chaambwa H, OBGY
 The end

Dr Chaambwa H, OBGY