Fertility control

1. Fertility control د0 بتول عبد الواحد هاشم

2. Contraception: Classification: Hormonal contraception: • Combined oral contraception • Combined hormonal patches • Progestogen-only preparation • -Progestogen-only pills • -injectables • -subdermal implants

3. Intrauterine contraception • Copper intrauterine device • Hormone-releasing intrauterine system(IUS) • Barrier methods • Condoms • Female barriers • Coitus interruptus • Natural family planning • Emergency contraception • Sterilization • Female sterilization • Vasectomy

4. The number of failures per 100 women year(HWY): is the number of pregnancies if 100 women were to use the method for 1 year • One- method failure is either to imperfect use (user failure)- most common-, or to intrinsic method failure.

5. Contraceptive method failure rate per HWY • COCP 0.1-1 • POP 1-3 • Depoprovera 0.1-2 • Implanon 0 • Copper bearing IUD 1-2 • LNIUS 0.5 • Male condom 2-5 • Female diaphragm 1-15 • Persona 6 • Natural family planning 2-3 • Vasectomy 0.02 • Female sterilization 0.13

6. HORMONAL CONTRACEPTIVE METHODSCOMBINED ESTROGEN AND PROGESTIN METHODSOral Contraceptive Pills (OCPs) Formulations • Modern preparations contain ethinyl estradiol in a daily dose of between 20-35 mcg, higher doses of estrogen are strongly linked to increased both arterial and venous thrumbosis, • Progestogens in the pills are classed as second (norethisterone acetate or levonorgestrel) or third generation (gestoden, desogestrel, norgestimate) or antimineralocorticoides and antiandrogenic(drospirenone). • Monophasic pills have fixed estrogen/progesterone dose • Biphasic and triphasic preparations have 2 or 3 incremental doses of estrogen and progesterone. • They either contain21 pills with 7 days pill-free period • Or ED-every day preparations- that include 7 placebo pills

7. mechanism of contraception • Oral contraceptives place the body in a pseudo-pregnancy state by interfering with the pulsatile release of follicle-stimulating • hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. This pseudo-pregnancy state suppresses ovulation • 2- thickening the cervical mucus to render it less penetrable by sperm and • 3-changing the endometrium to make it unsuitable for implantation.

8. Decrease risk of serious diseases • Ovarian cancer • Endometrial cancer • Ectopic pregnancy (combination pills only) • Severe anemia • Pelvic inflammatory disease Improve quality-of-life problems • Iron-deficiency anemia • Dysmenorrhea • Functional ovarian cysts • Benign breast disease • Osteoporosis (increased bone density) • Rheumatoid arthritis Treat/manage many disorders • Dysfunctional uterine bleeding • Control of bleeding in bleeding disorders and anovulation • Dysmenorrhea • Endometriosis • Acne/hirsutism • Premenstrual syndrome (PMS)

9. Contraindications to Combination Estrogen-Progesterone Contraceptives Absolute Contraindications • Circulatory disease • -ischemic heart disease • -cerebrovasular accidents • -significant hypertension • -arterial or venous thrombosis • -any acquired or inherited prothrombotic tendency • -any significant risk factors for cardiovascular disease • Acute or severe liver disease • Estrogen dependant neoplasm, particularly breast cancer • Focal migrane Relative Contraindications • Generalized migrane • Long term immobilization • Irregular undiagnosed vaginal bleeding • Less severe risk of cardiovascular diseases e.g. obesity, heavy smoking, diabetes.

10. Side effects • Minor side effects: • CNS: headache, depression, loss of libido • GIT: nausea, vomiting, weight gain, bloatedness, gallstones, cholestatic jaundice • Genitourinary: irregular bleeding, vaginal discharge (ectropion) • Growth of fibroids • Breast: mastalgia, increased risk of breast cancer. • Miscellaneous: chloasma, leg cramps

11. Serious side effects: Venous thromboembolism:the higher dose estrogen in the pills the higher prothrombotic tendency,3rd generation progestogens have twice the risk of thrumboembolism(TE) than 2nd generation progestogens. • Risk of VTE • 5/100000 general population • 15/100000 2nd generation COC • 30/100000 3rd generation COC • 60/100000 pregnancy Arterial disease: • Cerebrovascular accident (CVA), Myocardial infarction (MI) have extremely small increased risk of occurrence, however smoker women more than 35 years old have increased risk for such complications. Around 1% of women taking COC will become significantly hypertensive and should be advised to stop pills.

12. Breast cancer: • Data shows small increase in risk of developing breast ca among current COC users, this is more significant for women in their 40s as the background risk for breast cancer is higher. • Beyond 10 years of stopping the pills there was no increased risk of breast cancer for younger user. Cervical cancer: • Barrier methods confer some protection and any association identified in epidemiological studies may be simply the result of inadequate adjustment for sexual behavior. Women with persistent infection with HPV using hormonal contraception for more than 5 years had increased relative risk of cervical cancer of 2.8. • Recent evidence has suggested an increased risk of adenocarcinoma among long term users but this is a rare tumor.

13. Liver cancer: • Benign hepatic adenoma is a rare consequence of COC use Ovarian, endometrial and colon cancer: • COCP protects against ovarian cancer with 50% reduced risk of epithelial type after 5 year of use the protective effect last for at least 10 years after pill use stops. The effect may be related to the reduction of total number of ovulation and therefore rupture of ovarian capsule. And COCP reduces the risk of endometrial cancer the effect is strongly related to duration of use and is sustained for perhaps as long as 15 years after stopping the pills. There is some evidence to suggest that COC may confer protection against colon cancer.

14. How late are you? Less than 12 hr don't worry. • Just take delayed pill at once and further pills as usual • more than 12 hr take the Most recently delayed now, discard any earlier pills use extra precautions for the next 7 days • how many pills are left in the pack after the most • recently delayed pill • ,<7 pills>7 pills • When you have finished • The pack, leave the usual 7D break • When you have finished the pack,before starting next pack • start the next pack next day without a break

15. combined hormonal patches Transdermal patch containing estrogen and progestogen, are applied weekly for 3 wk after which there is a patch –free wk. contraceptive patches have the same risks/benefits as COC, although they are more expensive, may have better compliance. limited data suggests that the overall average estrogen concentration is higher, Therefore, these patients should be made aware of the possible increased risk of thromboembolism, specifically DVT and PE in combined hormonal patches users. There does not appear to be an increased risk of heart attack and stroke in these patients.

16. Vaginal Estrogen and Progestin Hormonal Contraception-(NuvaRing): The ring is placed in the vagina for 3 weeks (it is likely effective for 4 weeks), and is removed for 1 week to allow for a withdrawal bleed. Again, this hormone-free period can be skipped to allow for continuous dosing, typically for 3 months.

17. Progestogen –only contraception(PO-CONTRACEPTION) • Progesterone-only contraception consists of oral, injectable, implantable, and intrauterine options (the Mirena IUS) • These all function primarily using the same mechanisms: thickening the cervical mucus, inhibiting sperm motility, and thinning the endometrial lining so that it is not suitable for implantation.higher dose progesterone-only methods will also act centrally and inhibit ovulation.

18. The common side effects of PO methods include: • Erratic or absent menstrual bleeding. • Functional ovarian cyst(persistent follicle) • Breast tenderness • Acne • Sexually transmitted infection hormonal contraception may be associated with an increased risk of Chlamydia and gonorrhea, especially with depoprovera which causes hypoestrogenism, thinning of vaginal epithelium may increase the risk of infection.

19. Relative contraindications for use of POC: • Breast feeding at least 6 wk postpartum • Current DVT, PE • Previous breast cancer with no evidence of disease for 5 yr • Active viral hepatitis • Benign hepatic adenoma • Severe decompensated cirrhosis • Malignant hepatoma • Current or history of ischemic heart disease , stroke • Migraine with aura • Unexplained vaginal bleeding • Multiple risk factors for arterial cardiovascular disease • BP>160/100 mmHg • Vascular disease • Diabetes with nephropathy

20. Progestin-Only Oral Contraception Pills (The Minipill): Suits women who cannot take the COC, but have relatively higher failure rate, ideal for women at times of lower fertility, if fail make those women at higher risk of ectopic pregnancy. Older preparation contain 2nd generation at low dose, the newer ones contain 3rd generation progestogen at higher dose to inhibit ovulation. The POP is taken every day without a break

21. Particular indication for POP include: • Breast feeding • Older age • Cardiovascular risk • Diabetes

22. Injectables progestogens: • Depot medroxyprogesteron acetate( depoprovera) 150 mg injection last for12-13 wk • Norethisterone enanthate 200mg only last for 8wk • Depoprovera is highly effective method of contraception • Most women develop very light or absent menstruation • It improves PMS other menstrual problems like painful or heavy periods. • Particularly suits patients with poor compliance • Particular side effects • Weight gain 3 Kg in the 1st year. • Delay in regaining fertility( 6mo.-1yr) • Persistent menstrual irregularities • With very long term use increases osteoporosis

23. The Effects of Depo-Provera Use on Bone Mineralization • Bone density is decreased in women using Depo-Provera • The decrease in bone density is most rapid in the first year of use • The decrease in bone density increases with length of use • The decrease in bone density is reversible and occurs over 6 mo to 2 years • There is no role for the use of bone density screening (DEXA) in DMPA users • There is no role for the use of bisphosphonates, estrogens, SERMS in DMPA users • Women on Depo-Provera should be encouraged to take calcium and vitamin D, to • stop smoking, and to do regular weight-bearing ex

24. Subdermal implant: • Implanon consist of single silastic rod that is inserted locally under local anesthesia in to upper arm it superseded the 6 rod implant norplant. It's highly effective and there have been no genuine failures reported with it. • It lasts for 3 years, particularly benefit poor compliant women who need reliable long term contraception, with rapid regaining of fertility.

25. Patient management: Careful teaching and explanation of the method, detailed past medical and family history, examine the BP, body weight. Doing pelvic and breast exam are not necessary. Start with 30 mcg EE, 2nd generation progestogens as these are safest and cheapest; explain what to do if they miss taking their pills

26. How late are you? Less than 12 hr don't worry. • Just take delayed pill at once and further pills as usual • more than 12 hr take the Most recently delayed now, discard any earlier pills use extra precautions for the next 7 days • how many pills are left in the pack after the most • recently delayed pill • ,<7 pills>7 pills • When you have finished • The pack, leave the usual 7D break • When you have finished the pack,before starting next pack • start the next pack next day without a break