CONTRACEPTION

1. CONTRACEPTION Dr. Mona A. Almushait Dean, Girl’s Centre Associate Professor & Consultant Obstetrics and Gynaecology College of Medicine King Khalid University Abha, Saudi Arabia

2. Methods of Contraception

3. Combined Estrogen and Progesterone Contraceptives Oral contraceptive pills Monthly injections Transdermal patches Vaginal rings 1. Combined Hormonal Products

4. Mode of action: Suppression of the LH surge (to prevent ovulation) →to inhibit ovulation Thickening of the cervical mucus (to prevent sperm entering the upper genital tract) Other mechanisms: → slowing of tubal transport → atrophy of the endometrium

5. Thromboembolism Post pill amenorrhea Cerebrovascular accidents Increased in Cholelithiasis (cholestatic jaundice) HTN Benign hepatic tumors (Hepatoma) Headache in the week off Complications of Estrogen–Containing Contraceptives:

6. Contraindications to the Use of Estrogen–Containing Contraceptives ABSOLUTE Arterial thrombosis Venous thrombus (Thromboembolism) Pulmonary embolism Coronary vascular disease, IHD →cardiomyopathy, vascular heart disease Past cerebrovascular accident Pulmonary HTN Current pregnancy Breast cancer within the last 5 years

7. ABSOLUTE Cont’d Endometrial cancer Hepatic tumor or abnormal liver function, Dubin–Johnson or Rotor syndrome, known gallstones Unexplained abnormal uterine bleeding Age >35 and cigarette smoking Uncontrolled hypertension History of melanoma Hyperlipidaemia, focal and crescendo migraine Trophoblastic disease

8. RELATIVE Risk factor for arterial disease Complicated prolonged Diabetes Estrogen–dependent neoplasm Depression, Hyperprolactinemia Severe varicose veins Hypertriglyceridemia Increasing age, smoking, obesity, migraine

9. PoPs are taken as a continuous preparation, in 28 day packs. Taken at the same time each day Mode of action: Thicken the cervical mucus Inhibit ovulation Twining the endometrium Progestin–Only Hormonal Methods of Contraception (POPs)

10. Safe → when oestrogen–containing pills cause side effects, or contraindicated Smokers, immediately post–partum, breastfeeding, risk of DVT, hypertension, migraine, or diabetes, PMS Pills most frequently used by breastfeeding women Side effects: Menstrual changes Amenorrhea ↑ functional ovarian cyst ↑ risk of ectopic pregnancy Acne, headache, breast tenderness, nausea, irregular bleeding Weight change ↑Breast cancer diagnosis

11. DMPA (Depo–Provera) 150 mg every 3 months, I.M. Suppresses gonadotropins to inhibit ovulation Change cervix mucus (thickening) Twining endometrium Advantages: High efficacy No need to remember to take a pill Use when oestrogen contraindicates No increased in ovarian cyst or risk of ectopic pregnancy

12. Disadvantages: Delayed of fertility, weight gain, irregular bleeding and amenorrhea ↑ risk of Osteoporosis due to long term Medroxy progesterone acetate Contraindications: Pregnancy Severe arterial disease Undiagnosed vaginal bleeding Liver disease

13. Applied once a week to the abdomen, buttock, upper outer arm. The patch releases 150 µg of norelgestromin and 20 µg of ethinyl estradiol to inhibit ovulation. 3-consecutive 7-day pathches (21 days) are applied followed by 1 patch free week per cycle. Transdermal Patch

14. Advantages: Very effective Rapidly reversible Disadvantages: Requires a prescription Skin reactions Slight increase in risk of VTE compared with COCs

15. A thin, transparent, flexible ring that contains oestrogen/progestogen hormones. It stops ovulation and thickens the cervical mucus. Advantages: Easy to use Can be worn for 3 weeks Disadvantages: Does not protect against STD Spotting Increased vaginal discharge Vaginal Ring

16. II. Barrier and Behavioral Methods

17. Advantages: ↓transmission of STD, HIV, Chlamydia and Gonorrhea Easily obtained Disadvantages: Allergy Loss of sensation Slippage/breakage Male Condom

18. To be filled and coated with spermicide 84% to 94% effective for pregnancy prevention Must be left in place for at least six hours. Advantages: Easy use Protection from sexually transmitted infections Disadvantages: Cystitis Skin irritation Diaphragm and Cap

19. A lubricated polyurethane Advantages: Prevents the transmission of infection No hormonal side effects Disadvantages: Loss of sensation Can break or leak Female Condom

20. Jellies come in tubes and are usually used with a diaphragm or cervical cap. It allows for immediate protection, which lasts for about 1 hour. Jelly

21. Small, donut-shaped foam that contains a spermicide A non hormonal barrier method of birth control Vaginal Contraceptive Sponge

22. Advantages: It kills the sperm It blocks the semen fluids from entering the cervical canal No hormones are involved Disadvantages: Irritation No protection against infection Vaginal Contraceptive Foam

23. A paper-thin translucent film that contains a spermicide Its is placed in the vagina or near the cervix where it dissolves in seconds It is effective for about one hour Film

24. Behavioral Methods Natural family planning Tracking basal body temperature Checking the consistency of cervical mucus →Moist, sticky, white pre–ovulation, clear, copious and stretchy spinnbarkheit→ The most fertile time Time in cycle →Ovulation occurs every 12–16 days before a period →Pain from ovulation, breast change → less Lactational amenorrhea Withdrawal or coitus interruptus

25. III. Longer Term Progestin Implants and Intrauterine Devices

26. It is placed in the s/c layer of the medial aspect of a woman’s upper arm to release steady amounts of Levenogestrel → 5 years Have low circulatory levels of progestin Suppress ovulation and change cx mucus Twining endometrium Implant

27. Disadvantages: Vaginal spotting Weight gain Hair or skin changes Headaches Depression Decreased libido

28. Contains 52 mg of Levenogestrel 20 µg of Levenogestrel every 24-hr. T–shape Effective for at least 5 years Levenogestrel–Releasing Intrauterine System (LNG–IUS)

29. Mode of action: Thickens the cx mucus Twins the endometrium→atrophic endometrium Inhibition of ovulation Disadvantages: Amenorrhea Irregular bleeding for the first 3 months ↑ functional ovarian cyst Expulsion and perforation

30. Contraindications: Pregnancy Active liver disease Severe arterial disease Undiagnosed irregular bleeding Mechanical heart valves Untreated STD Hx of ovarian or endometrial carcinoma

31. Mode of action: Copper is spermicidal It is inserted in the first 7 days of cycle with antibiotics cover Inflammatory changes to prevent implantation Disadvantages: Pregnancy with I.U.C.D. Increased rate of Ectopic pregnancy ↑Menorrhagia ↑ PID Perforation and expulsion Actinomycosis→ cx smear Lost coil Copper T380A I.U.D.

32. IV. Female sterilization and Vasectomy

33. Advantages: Permanent birth control Immediately effective Requires no daily attention Not messy Cost-effective in the long run Disadvantages: Does not protect against STD Requires surgery May not be reversible Possible regret Possibility of Post Tubal Ligation Syndrome Sterilization • Permanent sterilization is the most common method of birth control used. • Mini Laparotomy sterilization • Laparoscopic sterilization

34. filshie clip tubal ligation • One common form of laparoscopic (camera) sterilization is the use of Filshie clips to occlude both fallopian tubes. Hulka clip sterlization • One common form of female sterilization is the use of Hulka clips to block the fallopian tubes. VASECTOMY (interruption of the vas deferens) • It is a minor surgical procedure wherein the vasa deferentia of a man are severed, and then tied/sealed in a manner which prevents sperm from entering the seminal stream.

35. Risks include: • Infection • Bleeding • Scrotal pain or swelling at the time of the procedure