FAMILY PLANNING ( CONTRACEPTION ) Dr. Huda. M. M CABOG , FIBOG

1. FAMILY PLANNING ( CONTRACEPTION) Dr. Huda. M. M CABOG , FIBOG

2. People are using different types of contraception at different stage of life. • There is no one method that will suit everyone. • There is no perfect method of contraception . • Each method have a balance between advantage and disadvantages. • Unintended pregnancy is still common .

3. The characteristics of ideal contraceptive method would be: • Highly effective • No side effects or risks . • Cheap. • Independent of intercourse and requires no regular action on the part of the user. • Have non- contraceptive benefits. • Acceptable to all cultures and religions. • Easily distributed and administrated by non-healthcare personnel.

4. Classification of contraception : I-Combined hormonal contraception ( the pills, patches , vaginal ring). II- progestogen only preparations ( progestogen only pills, injectible , subdermal implants ). III – hormonal emergency contraception.

5. IV-Barrier methods ( condoms, coitus interrupts , female barriers , natural family planning). V– sterilization ( female sterilization, vasectomy) VI–intrauterine contraception ( copper intrauterine contraception IUD , hormone releasing intrauterine system IUS).

6. Failure rates are expressed as the number of pregnancies if 100 women were to use a method for one year. The effectiveness of a method depends on : 1- how it works; 2- how easy it to use.

8. Contraindications ( is generally safe , some methods have very rare but serious side effects and risks). WHO guidelines on assessing the criteria for contraception use. Falls into four categories as: Category I : No restriction for the use of the method . Can be used in any circumstance.

9. Category II : • The advantage of using the method generally out weighs the theoretical or proven risks . • Can be used generally. • Category III: • The theoretical or proven risks usually out weighs the advantages of using the method. • Requires careful clinical judgement and access to clinical services. • Not usually recommended unless other, more appropriate methods are not available or not acceptable

10. Category IV : • represents an unacceptable health risk if the contraceptive method is used. • So don’t use it. • Non contraceptive health benefits : • Condoms prevents sexually transmitted infections and with diaphragms can protect against cervical cancer.

11. Many methods containing hormones ( Mirena, COCP ) used in painful and heavy periods. • COCP can protect against ovarian and endometrial cancer. • Counseling: • When you prescribe a contraception for the patient you should counsel her regarding the mode of action; effectiveness ; side effects or risks; benefits ; how to use the method and STI and HIV risks reduction and prevention.

12. Combined hormonal contraception • I-Combined oral contraceptive pills: • COC was first licensed in UK in 1961. • It contains a combination of two hormones ; a synthetic estrogen and progestogen ( a synthetic derivative of progesterone). • The dose of estrogen and progestogen have been reduced dramatically to improve its safety profile

13. COC is easy to use . • Offers very high protection against pregnancy ; with many other beneficial effects. • It is mainly used by young healthy women, independent of intercourse . • For maximum effectiveness, COC should always be taken regularly at roughly the same time of each day

14. Mode of action : acts both centrally & peripherally . I- inhibition of ovulation ( E2 & progestogen suppress the release of FSH & LH which prevents follicular development within the ovary and ovulation. II- making the endometrium atrophied and hostile to implantation, altering cervical mucosa to prevent sperm ascending into uterine cavity

15. Formulation of COC

16. There are many different formulations and brands of COC , which increasingly offer different hormones, dosage , and pill taking schedules. • Oestrogens:- • Most modern preparations contain the estrogen ethinylestradiol EE in a daily dose of between 15 -35 Mg .

17. Those containing lower dosages are associated with slightly poorer cycle control. • Those containing higher dosage of estrogen are associated with increased risk of both arterial and venous thrombosis.

18. Progestogens • Most COC contains progetogens that are classed as 2nd or 3rd generation . • 2nd generation pills contains derivative of norethindrone and levonorgestrel. • The 3rd generation pills include desogestrel , gestodene and norgestimate.

19. Newer generation includes drosprinone and dienogest. • Dainette®: is acombined preparation containing strong anti androgen cyproterone acetate ; used in the treatment of acne and hirsutism .

20. Regimens : • Monophasic pills are almost used and contain daily dosage of estrogen and progestogen • Biphasic triphasicquadriphasic preparations have two ,three ,four incremental variation in hormones dosage but are more complicated, and have little advantages

21. Most brands contain 21 pill to be taken daily followed by a 7 day pill free interval ( the traditional 21/7 model). • There are also some every day preparations include seven placebo pills that taken instead of pill-free interval.

22. Contraindications: • Most of these contraindication ( category III & IV) relate to the side effect of sex hormones on cardiovascular and hepatic systems. • Women should ideally discontinue COC before any pelvic or lower limbs operations because of the risk of venous thromboembolization

23. Absolute contraindications: • Breasfeeding <6 wks postpartum . • Smoking > 15 per day and age >35 y. • Multiple risk factors for cardiovacular disease. • Hypertension systolic BP >160 or diastolic or diastolic BP > 110 mmHg. • Hypertension with vascular disease. • Current Hx of DVT or pulmonary embolism

24. Major surgery with prolonged immobilization. • Known thrombogenic mutations . • Current Hx of IHD. • Current Hx of stroke. • Complicated vascular heart disease. • Migraine with aura. • Migraine without aura but continued beyond 35 y old.

25. Current breast cancer. • Diabetes for > 20 y or with severe vascular disease or with severe nephropathy , retinopathy or neuropathology. • Active viral hepatitis . • Severe cirrhosis. • Benign or malignant liver tumors.

26. Relative contraindications: • Multiple risk factors for arterial disease. • Hypertension : systolic BP 140-159 or diastolic BP 90-99 mmhg. • Some known hyperlipidemia. • Diabetes with vascular disease. • Smoking , 15 cigarette /day and age> 35 y. • Obesity. • Migraine even without aura and age> 35y.

27. Breast cancer > 5 y without recurrence . • Breast feeding until 6 months postpartum. • Postpartum and not breastfeeding until 21 days after childbirth. • Current or medically treated gallbladder disease. • History of cholestasis related to COC. • Mild cirrhosis . • Taking rifampicin or certain anticonvulsants.

28. Side effects and risks: • The vast majority of women tolerate COC. • Many minor side effects will settle within a few months of starting COC ; although of that they are frequently leads to early discontinuation. • CNS : depressed mode, mood swings, headaches and loss of libido.

29. GIT: nausea , perceived wt gain and bloatedness. Reproductive system: breakthrough bleeding and increased vaginal discharges. Breasts : pain and enlarged breasts. Miscellaneous : chloasma ( facial pigmentation which worsens with time on COC , fluid retention and change in contact lens

30. Venous-thromboembolism(VTE): • COC increase the risk 3-5 fold. • Estrogens alter blood clotting and coagulation in a way that induces a pro-thrombotic tendency – the exact mechanism is unknown. • The type of progestogens also affects the risks of VTE ( with using COC containing 3rd generation the risk is twice as with using COC containing 2nd generations)

31. Arterial disease : • Is much less common than VTE but more serious. • Cigarette smoking and high BP will both increase the risk. • 1% of women who are taking COC become significantly hypertensive. • Breast cancer risk is slightly increase within current users

32. Drug interactions: • This can occur with enzyme inducing agents ( some antiepileptic drugs) this need to use COC containing 50Mg EE. • Some broad spectrum antibiotics can alter the intestinal absorption of COC , so additional contraceptive methods should be recommended during treatment and 1 wk thereafter.

33. Positive health benefits : • Used to treat heavy painful periods. • Improve premenstrual syndrome . • Reduce the risk of PID. • Long term protection against both ovarian and endometrial cancers. • Used in the treatment of acne.

34. Patient management: • Careful teaching and explanation of the method. • A detailed family • and past medical • history should • be taken . • Checking BP.

35. Management of missed pill

36. Combined hormonal patches: • Containing estrogen and progestogen. • Releases norelgestromin 150 mg and ethinylestradaiol 20 mg / 24 hr . • Patches are applied weekly for 3 wks , then there is patch free week. • More expensive , had better complains.

37. Combined hormonal vaginal rings: • Is made of latex free plastic has a diameter of 54mm. • It releases a daily dose of 15 Mg EE, and 120 Mg etonorgestrel. • The ring is worn for 21 day and removed for 7 days when withdrawal bleeding occur. • Easy insertion and removal.

38. Progestogen- only contraception • Avoid the risks & S/E of estrogen. • The current methods of progestogen only contraception are: • 1- progestogen only pills (POP) minin pills. • 2- subdermal implant( Implanon). • 3-injectables (Depo- provera, noristerat). • Hormone releasing intrauterine system (Mirena).

39. All progestogen only contraception methods work by • Local effect : • on cervical mucosa ( making it hostile to ascending sperm) . • on the endometrium ( making it atrophied & thin. • prevent implantation and sperm transport. • the higher doses will act centrally and inhibit ovulation ( highly effective).

40. Progestogen only pills (POP): • Is ideal for women who like the convenience of pills taking but wish to avoid COC. • It is taken every day without a break. • Its failure rate is more than COC; if POP failed there is slightly higher risk of ectopic pregnancy.

41. POP contains the 2nd generation of progestogen ( norethisterone or norgestrel ) ; and 3rd generation (desogestrel) . • The dose of desogestrel in POP (Cerazette) is highly effective to inhibit the ovulation . • Indications for POP : breastfeeding , older age , cardiovascular risk factors .

42. Injectableprogestogen: 1- medroxyprogesterone acetate 150 mg ( Depo- Provera/ DMPA). 2- norethisterone enanthate 200 Mg ( noristerat); only last for 8wk

43. Injectableprogestogen: • 1- medroxyprogesterone acetate 150 mg ( Depo- Provera/ DMPA). • Injection lasts for 12 wk with a2 wk grace period thereafter. • Highly effective and given by deep IM injection. • Cause light or absent menstruation.

44. Will improve PMS and used in the treatment of heavy and painful periods • MPA causes low estrogen level that associated with loss of bone mineral density (osteoporosis) & this is reversed after MPA stop.

45. Particular S/E of DepoProvera include: • Wt gain of around 2-3 kg in the 1st y of use. • Delay in return to fertility aroud 6 months. • Persistently irregular period ( amenorrhea)

46. Subdermal implants:

47. Implanon ( single silastic rod inserted subdermally under local anesthia to the upper arm. • It release progestogenetogogestrel 25-70 mg daily ( the dose is decreases with time) this will metabolized into third generation progetogendesogestrel. • It lasts for three years .

48. Implanon is suitable for women who have difficulty to a pill and want highly effective long term contraception. • Irregular vaginal bleeding is a major reason for early discontinuation . • Need special health professional training to insert and remove Implanon.

49. Intrauterine contraception

50. Is highly effective and popular. • It is medium to long term method of contraception that is independent on sexual intercourse. • Intrauterine contraception protects against intrauterine and ectopic pregnancy, but if pregnancy occur there is a high chance to be ectopic.