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CHAPTER 10 Family Planning

CHAPTER 10 Family Planning. NOVAK ’ S GYNECOLOGY . OBGY R1 Lee Eun Suk. Family Planning. The rapid growth of the human population in this century threatens the survival of all At this present rate, the population of the world will double in 47 years

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CHAPTER 10 Family Planning

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  1. CHAPTER 10 Family Planning NOVAK’S GYNECOLOGY OBGY R1 Lee Eun Suk

  2. Family Planning • The rapid growth of the human population in this century threatens the survival of all • At this present rate, the population of the world will double in 47 years • That of many of the poorer countries of the world will double in about 20 years

  3. Family Planning • For the individual and for the planet, reproductive health requires careful use of effective means • Prevent both pregnancy and sexually transmitted diseases • The contraceptive choices made by American couples in 1995 • For couples older than 35 years of age • Sterilization is the number one choice • For younger couples • Oral contraceptives (OCs) are the most used methods • The condom ranks second

  4. T10.1

  5. Family Planning • Abortion is an obvious indicator of unplanned pregnanacy • Abortion ratios by age group indicate that the use of abortion • Greatest for the youngest women • Least for women in their late 20s and early 30s

  6. Family Planning • Young people are much more likely to experience contraceptive failure • Their fertility - greater than of older women • More likely to have intercourse without contraception

  7. Efficacy of Contraception • Factors affecting whether pregnancy will occur • The fecundity of both partners • The timing of intercourse in relation to the time of ovulation • The method of contraception used • The intrinsic effectiveness of the contraceptive method • The correct use the method • A pregnancy rate per year can be calculated using the Pearl formula • Dividing the number of pregnancies by the total number of months contributed by all couples, then multiplying the quotient by 1,200 • Rates of pregnancy with different methods are best calculated by reporting two different rates derived from multiple studies

  8. T10.2

  9. Safety • Some contraceptive methods have associated health risks ; Areas of concern are listed in Table 10.3 • Most methods provide noncontraceptive health benefits in addition to contraception • Oral contraceptives reduce the risk for ovarian and endometrial cancer and ectopic pregnancy • Barrier methods and spermicides provide some protection against STDs, cervical cancer, and tubal infertility

  10. T10.3

  11. Cost • Intrauterine devices (IUDs) & subdermal implants • Expensive initial investment • Prolonged protection for a low annual cost • Sterilization & the long-acting methods • The least expensive over the long term

  12. T10.4

  13. Nonhormonal Methods • Coitus Interruptus • Lactation Amenorrhea • Periodic Abstinence or Natural Family Planning • Condoms • Vaginal Spermicides • Vaginal Barriers • Intrauterine Devices

  14. Coitus Interruptus • Withdrawal of the penis from the vagina before ejaculation • Advantages • Immediate availability • No cost • Reduced the risk for STDs • Failure rate ( reported by The Oxford Study ) • 6.7 per 100 woman-years • The penis must be completely withdrawn both from the vagina and from the external genitalia

  15. Lactation Amenorrhea • Ovulation is suppressed during lactation • The suckling of the infant • → prolctin levels↑ • → gonadotropin-releasing hormone (GnRH)↓ • → luteinizing hormone (LH)↓ • → follicular maturation↓ • Another method of contraception should be used from 6 months after birth, or when menstruation resumes • Progestin only OCs, implants, injectable contraception • Barrier methods, spermicides, IUDs • The risk for the breast cancer↓

  16. Periodic Abstinence or Natural Family Planning • Couples attempt to avoid intercourse during the fertile period around the time of ovulation • A variety of methods • The calendar method • The least effective • The mucus method (Billings or ovulation method) • To predict the fertile period by feeling the cervical mucus • The symptothermal method • The first day of abstinence is predicted either from the calendar, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months • The end of the fertile period – by use of basal body temperature

  17. Periodic Abstinence or Natural Family Planning • Efficacy • 3.1% probability of pregnancy in 1 year for the small proportion of couples who used the method perfectly • 86.4% for the rest • Vaginal infection increase vaginal discharge • ↑ Complicating the use of the method • Accurate advance prediction of the time of ovulation • ↑ Facilitate both the use & efficacy

  18. Periodic Abstinence or Natural Family Planning • Risks • Conceptions resulting from intercourse remote from the time of ovulation • ↑ Spontaneous abortion than contraceptions from midcycle intercourse • → Malformations are not more common

  19. Condoms • Latex rubber condoms • 1840s due to vulcanization • Hold the seminal fluid → preventing its position in the vagina • Prelubricated with the spermicide • ↑ More effective • The risks for condom breakage • About 3%

  20. Condoms • Sexually Transmitted Diseases • Latex condoms and other barrier methods • ↓ the risk for STDs • ↓ Gonorrhea, ureaplasma, and PID and its sequelae (tubal infertility) • Chlamydia trachomatis , herpes virus type 2,HIV, and hepatitis B → did not penetrate • Some protection from cervical neoplasia • Latex allergy could lead to life-threatening anaphylaxis • Nonlatex condoms of polyurethane and Tactylon are now available

  21. Condoms • Female Condoms • Vaginal pouches made of polyurethane are available • Efficacy trials • The pregnancy rate : only 2.6% • No signs of trauma, and the bacterial flora is not changed

  22. Vaginal spermicides • Nonionic surface-active detergents that immobilize sperm • Aerosol foams provided rapid dispersal throughout the vagina • the best protection • Nonoxynol-9 • ↓ the risk for bacterial vaginosis and other STDs, including HIV • Toxic to the lactobacilli that normally colonize the vagina • vaginal colonization with bacterium Escherichia coli • Concerns about possible teratogenicity • No greater risk for miscarriage, birth defects, or low birth weight

  23. Vaginal Barriers • Vaginal diaphragm, cervix cap, vault cap, vimule (Fig. 10.4) • They are safe • The noncontraceptive benefit • Protection from STDs, tubal infertility & cervical neoplasia

  24. F10.4

  25. Vaginal Barriers • Diaphragm • Circular spring covered with fine latex rubber (Fig 10.5) • Coil-spring & flat –spring → flat oval compressed for insertion • Proper fitting & proper use are key to its effect • Spermicide is always prescribed for use

  26. Fig 10.5

  27. Risks • ↑The risks for bladder infection • Relative risk : 1.42, 2.83, and 5.68 for use 1, 3, or 5days in a week • → Smaller-sized, wide-seal diaphragm or cervical cap • An study comparing cases of toxic shock with controls • No increased risk from diaphragm use

  28. Cervical caps • Much smaller than the diaphragm • Does not contain a spring in the rim • Covers only the cervix with spermicide • Efficacy • A first-year pregnancy rate of 11.3 per 100 women • Near perfect use → a first-year pregnancy rate of 6.1 per 100 • The cap worn for more than 72 hours → pregnancy rate ↑ • The failure rates with “perfect use” → higher than the diaphragm • Parous women more failures than nulliparous women

  29. Fitting Cervical caps • The cervical size is estimated and palpation • The cap is inserted by compressing it between finger and thumb and placing it through the introitus, dome outward • Before use, the cap is one-third filled with spermicidal jelly or cream

  30. Cervical caps - Risks • Negative cervical cytology progressed to dysplasia in 4% • Other studies - not found this effect • In contrast, Koch - to be protected from dysplasia • Not associated with cystitis • Toxic shock – not reported

  31. Intrauterine Devices • Very important worldwide but play a minor role in contraception for the U.S. • High-dose copper IUD : TCU380, or ParaGard • Safe, long-term contraception with effectiveness equivalent to tubal sterilization • The third copper IUDs • T380A (ParaGard) : the progesterone-releasing T (Progestasert) • Bands of copper on the cross arms of the T • Copper wire around the stem • Total surface area of 380 mm of copper • Levonorgestrel-releasing T (Mirena)

  32. Mechanism of Action • Formation of “biologic foam” within the uterine cavity • Contains strands of fibrin, phagocytic cell & proteolytic enzymes • Copper IUDs • → Release a small amount of the metal • → Producing an even greater inflammatory response • Stimulate the formation of prostaglandin • Smooth muscle contraction & inflammation • → The altered intrauterine environment • ↓ Sperm passage • ↓ fertilization

  33. Mechanism of Action • The natural progesterone in the Progestasert • →endometrial atrophy • The levonorgestrel in the Mirena • Much more potent than natural progesterone • Blood levels of the hormone • Half of the levonorgestrel subdermal implant (Norplant) • → Block ovulation • The IUD is not an abortifacient • Contraceptive effectiveness • → not depend on interference with implantation

  34. Effectiveness • The copper T380A and the levonorgestrel T • Remarkably low pregnancy rates • Less than 0.2 per 100 woman-years • Total pregnancies over a 7-year period • The levonorgestrel T : 1.1 per 100 woman • The copper T380A : 1.4 per 100 woman

  35. Benefits • The ParaGard and the Mirena IUDs • Protect against ectopic pregnancy • Progesterone or levonorgestrel → Menstrual bleeding & clamping↓

  36. Risks • Infection • The relative risk for PID • Progestasert : 2.2 • Copper 7 : 1.9 • Saf-T-Coil : 1.3 • Lippes Loop : 1.2 • ↑Risk was detectable within 4 months of insertion • The rate of diagnosis of PID →1.6 cases per 1,000 women per year • Exposure to sexually transmitted pathogens • More important determinant of PID than the wearing of an IUD • PID with actinomycosis → only in women wearing an IUD

  37. Risks • Pelvic Inflammatory Disease • When PID is suspected in IUP-wearing woman • → The IUD should be immediately removed • → High-dose antibiotic therapy should be started

  38. Risks • Ectopic Pregnancy • In 5% of IUD wearers • d/t the fallopian tubes are less well protected against pregnancy than uterus • Copper T380A or levonorgestrel T • Compared with women using no contraception → 80% to 90% reduction in the risk for ectopic pregnancy • Greater reduction than that seen for users of barrier methods

  39. Risks • Fertility • ↑Twofold in the risk for infertility associated with tubal factors • The Oxford Study : giving birth just as promptly after IUD removal • Exposure to sexually transmitted pathogens • → Confers risk for infertility

  40. IUD – Clinical Management • Contraindications to IUD use • Pregnancy • A history of PID • Undiagnosed genital bleeding • Uterine anomalies • Large fibroid tumors • Chronic immune suppression • Copper allergy and Wilson’s disease

  41. Clinical Management • Insertion • The cervix is exposed with a speculum • The uterine cavity should be measured with a uterine sound • A paracervical block • →10mL of 1% lidocaine mixed with atropine (0.5mg) • Use of a tenaculum for insertion is mandatory to prevent perforation • With the ParaGard and the Progestasert, the outer sheath of the inserter is withdrawn a short distance to release the arms of the T • → gently pushed inward again to elevate the now-opened T against the fundus • With the Mirena IUD, insertion is somewhat different • The inserter tube loaded with the IUD is introduced into the uterus • Until the preset sliding flange on the inserter is 1.5 to 2cm from the external os of the cervix

  42. Clinical Management • Intrauterine Devices in Pregnancy • IUD should be removed as soon as possible • To prevent later septic abortion, premature rupture of the memb- ranes & premature birth • Options for management (if the IUD is present) • Therapeutic abortion • Ultrasound-guided intrauterine removal of the IUD • Continuation of the pregnancy with the device left in place • If the IUD is not in a fundal • → Ultrasound-guided intrauterine removal of the IUD • If the IUD is in a fundal • → Continuation of the pregnancy with the device left in place

  43. IUD – Duration of Use • Progestasert • Replaced at the end of 1 year • Copper T380A • Approved for 10 years • Levonorgestrel T • Approved for 5 years • Actinomyces-like particles should be found • Removal of the IUD • Treatment with oral penicillin

  44. IUD – Choice of Devices • Copper T380A & levonorgestrel T • Protection for many years • Low pregnancy rates • ↓Risk for ectopic pregnancy • Progestasert • Must be replaced annually • Risk for infection with each insertion • Increasing cost • ↑Risk for ectopic pregnancy • ↓ The amount of menstrual bleeding & dysmenorrhea

  45. Hormonal Contraception

  46. Hormonal Contraception • Female sex steroids , Synthetic estrogen Synthetic progesterone (progestin) , Progestin only • Combination OCs • The most widely used hormonal contraception • Administered for 21days beginning on the Sunday after a menstrual period → discontinued for 7 days to allow for withdrawal bleeding • Progestin-only formulations • Take every day without interruption

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