Presentation Contraception Main

8/6/2019 Presentation Contraception Main

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CONTRACEPTIONCONTRACEPTION

Dr. Jasdeep Singh SandhuDr. Jasdeep Singh SandhuPG 1PG 1 stst Year Year Dept. of PhysiologyDept. of Physiology

20/6/200820/6/2008


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CONTRACEPTIONCONTRACEPTION

DEFINITION:DEFINITION:

C ontraception, often defined synonymously with birthC ontraception, often defined synonymously with birthcontrol, is defined as a regimen of one or more actions, devicescontrol, is defined as a regimen of one or more actions, devicesor medications followed in order to deliberately prevent or or medications followed in order to deliberately prevent or reduce the likelihood of pregnancy or childbirthreduce the likelihood of pregnancy or childbirth


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M ETHODS OF CONTRACEPTION

PHYSICALBEHAVIORAL

M ETHODS UNDER DEVELOP M ENT


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BEHAVIORAL M ETHODS

FERTILITY AWARENESS

R hythm Method (obsolete)C harting/SoftwareNatural Family Planning (NFP) ( C atholic)

*3 FERTILITY SIGNSChanges in BBTChanges in Cervical mucusChanges in Cervical position

(Symptothermal Tracking Any 2 of the above)

COITUS INTERRUPTUS

AVOIDING SEXUAL INTERCOURSE

ABSTINENCE

LACTATIONAL


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M echanism : excludes sperm from female reproductivetract

Effectiveness: 0% failure rate

Ideal for adolescents at high risk for pregnancy and

STDs including HIV

Complications: recent data have shown an increase inteen sexual activity and pregnancy if no education isgiven on contraception

BEHAVIORAL M ETHODSABSTINENCE


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M echanism: Suckling causes increased prolactin, which inhibitsestrogen production and ovulation

2% typical use failure rate in 1st six mos.Candidates:

Amenorrheic women < 6 mos post-partum who exclusivelybreastfeed (90% of nutrition is breast milk)Women free of blood-borne infectionsWomen not on drugs that could effect baby

LAM Complications:Breastfeeding may increase the risk of mastitisR eturn of fertility or ovulation may precede menses.33-45% ovulate during 1st 3 mos.Encourage backup form of contraception as average duration

of breastfeeding in the

BEHAHIORALBR EASTFEEDING (LAM)


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PHYSICAL M ETHODS

Barrier methods

Hormonal methods

Emergency contraception

Ormeloxifene (Centchroman)

Intrauterine methods

Induced abortion

Sterilization


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Condoms:Condoms:

MaleMale

FemaleFemale

Cervical Barriers:Cervical Barriers:

C ontraceptive SpongeC ontraceptive SpongeC ervical C apC ervical C apDiaphragmDiaphragmSpermicideSpermicide

BARRIER M ETHODSBARRIER M ETHODS


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Sheaths of latex, polyurethane, or natural membranesthat may or may not have spermicideM echanism : Barrier that prevents sperm and infectionsfrom entering vagina

Effectiveness : 15% typical use failure rate

Candidates:C ouples not in mutually monogamous

relationshipsC ouples in which one partner has an STD/HIVC ouples starting other types of birth controlC ouples who cant use hormonal methods

BARRIER M ETHODSBARRIER M ETHODSMale C ondomsMale C ondoms


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Disposable single use polyurethane sheath placed in vaginaFlexible movable inner ring at closed end used to insert into vaginaFlexible outer ring to cover part of the introitusMechanism : Prevents passage of sperm and infections into the

vaginaFailure rate is high at 21% with typical useC andidates the same as for male condomsFemale condom is reusable only if the partner does not have anSTD

Disadvantages : Awkward and difficult to place Most users do not enjoy using female condom (88% of

women and 91% of men) Many couples complain about noise of condom

Barrier M ethod(Female C ondom)


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Thimble- shaped latex rubber device which has an inner ring thatprovides suction to keep cap on the cervixSpermicide is placed inside the cap before being placed on thecervix to kill sperm4 sizes : 22, 25, 28, 31 mmMechanism : barrier that prevents sperm migration into cervical canal

Advantages:May decrease risk of G C , C hl, and PIDC an be placed 6 hours prior to intercourseC an remain in vagina up to 48 hours for multiple acts of intercourse

Disadvantages:No protection against HIVPoor fit especially in parous womenFailure R ate : As high as 32% in parous women and 16% innulliparous women

Patient must leave in place at least 8 hours after intercoursebefore removing

Barrier M ethod(C ervical C ap)


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Latex rubber dome-shaped device that covers the cervixMechanism : prevents sperm from entering cervical canalThree types :

Arcing SpringC oil SpringWide Seal

Typical use failure rate : 16% in one year May reduce risk of PID and other infectionsR isks :

No protection from HIVDifficult to place around cervixMay fall out in women with pelvic relaxationMay cause vaginal erosions & infectionsMay cause reaction in latex allergicToxic Shock SyndromeUrinary Tract Infections

Barrier M ethod(Diaphragm)


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Most common is nonoxynol-9

Available in creams, films, foams, gels, suppositories,

sponges, and tablets

Best when used with barrier methods

29% typical use failure rate when used alone

Provides no protection against STDs and HIV

Barrier M ethod(Spermicide)


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Emergency Contraception(E C )

Any method used after unprotected or inadequatelyprotected sexual intercourse

Three types of E C available :

High dose progestin only ( Plan B)

Yuzpe method- 13 different combined oralcontraceptives (Preven)C opper IUD ( Paragard)


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M echanism:

Prevents fertilization and implantation. C ounsel

patients that this method does not abort apregnancy that is already implantedC ommon in women after an assault or rapeMost women will have a cycle 21 days after

completing emergency contraceptionIf patient does not have a cycle in 21 days, it isimportant to check a pregnancy test


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High dose progestin-only (Plan B):1.5mg Norgestrel at one time or in divided doses.Divided Dose : 1st dose within 72-120 hours of intercourse.

2nd dose 12 hours later.One dose : Both tablets within 72-120 hours of intercourse

Yuzpe M ethod (Preven):100mcg of ethinyl estradiol and 0.50 mg of levonorgestrel in each dose. 1st dose within 72 hours of intercourse and 2nddose 12 hours later

C opper IUDPlace within 5 days of unprotected coitusThis is usually given to women who plan to use the IUD for long term birth control

Interferes with implantation after fertilization


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Intrauterine Devices(IUDs)

C opper IUD (Paragard T

380 A) C opper is a spermicide that

inhibits sperm motility andacrosomal enzyme action

Lasts 10-12 years May increase bleeding and

dysmenorrhea Typical use failure rate is

0.8%

Mirena(Levonorgestrel)

Increases thickness of cervical mucus to inhibitsperm migration

Lasts up to 5 years Improves menorrhagia by

90% in most patients C auses amenorrhea in

many users Typical use failure rateis

0.1%

*Good for women in mutually monogamous relationshipsRisks:

Increased risk of PID within 1st 20 daysUterine perforationFainting with insertionExpulsion

Unexpected pregnancy following poor placement


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Combined Contraceptives(Estrogen & Progestin) : Oral

Ethinyl estradiol is the most commonly used estrogen in O C Ps

There are multiple forms of progestinsMonophasic : same amount of hormone in each active tablet

Multiphasic : varying amounts of hormone in each active pill

Most O C Ps have 21 active pills and 7 placebo pills

Mechanism :

Blocks ovulation Thickens cervical mucus Thins the endometrial lining


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Advantages: Improves acne Improves menorrhagia Decr. Dysmenorrhea R egulates cycle in

anovulatory women 50% reduction in ovarian

ca. with 5 year continuoususe. 80% reduction over 10years

R educes endometrial C a Decr. Benign breast dz.

Disadvantages: Spotting especially in 1st

few months May decr. Libido R equires daily pill intake No protection against

STDs and HIV Possible weight gain Post-contraception

amenorrhea


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Absolute Contraindications:

History of thromboembolism, MI,

stroke Impaired liver function K nown or suspected breast

cancer Undiagnosed abnormal

vaginal bleeding K nown or suspected

pregnancy Smokers over age 35 (

may use progestin-only pill)

Relative Contraindications:

Migraine headaches HTN- ok if


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Transdermal: Ortho Evra

GCF: Delivers 20 mcg of ethinyl estradiol and 150 mcg of

norelgestromin daily Takes 3 days to achieve a steady state of hormone in the blood

stream Patch is replaced once per week for 3 consecutive weeks Worn on abdomen, buttocks, upper outer arm, or upper torso Do not place on the breast

Advantages :

Only has to be replaced once per week May be taken continuously

Disadvantages : May slip off- provide pt. with an emergency patch Patch may be less effective in women who are > 198 pounds


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Vaginal Contraceptive Ring(NuvaRing)

GCF: C ombined hormonal contraception consisting of a 5.4 cm

diameter flexible ring 15 mcg ethinyl estradiol and 120 mcg of desogestrel

M echanism: suppresses ovulationTypical use failure rate: 8% Place in vagina and remove after 3 weeks Allow withdrawal bleeding and replace new ring Steady low release state Advantage is patient only has to remember to insert and remove

the ring 1x/ month May be placed anywhere in the vagina 150 mg IM every 3 months C ontraceptive level maintained for 14 weeks


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Depo Provera

150 mg IM every 3 months

C ontraceptive level maintained for 14 weeks

Failure R ate : 3% typical use failure rate

M echanism:

Thickens cervical mucus Blocks the LH surge Initiate treatment during the first week of menses


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Depo Provera

Advantages Long acting Estrogen-free Safe in breast-feeding C an be used in sicklecell

disease and seizuredisorder

Pt. does not have to takedaily

Increases milk quality innursing mothers

Disadvantages Irregular bleeding (70% in

first year) Breast tenderness Weight gain Depression Slow return of menses after

stopping use Decreases HDL cholesterol


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M ale Sterilization

Vasectomy: ligate or cauterize the vas deferensM echanism: interrupts vas deferens preventing passageof sperm into seminal fluidMay be done under local anesthesiaC heaper than female sterilizationFailure rate: < 0.15%Use contraception until completely azospermic for twoconsecutive sperm counts ( usually takes 12 weeks or

10-20 ejaculations)Does not affect ability to have an orgasm


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Female Sterilization

Interrupts the patency of fallopian tubes therebypreventing fertilization

Failure rate: Depends on method used ranges from 0.8-3.7%

May be performed through a minilaparotomy incision ,laparoscopically, or transcervically


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C ONT R AC EPTIONC ONT R AC EPTION(Methods under Development)(Methods under Development)

PraneemPraneem -- Polyherbal vaginal tablet is being studied as a spermicide, and aPolyherbal vaginal tablet is being studied as a spermicide, and amicrobicide active against HIV.microbicide active against HIV.BufferGelBufferGel -- Spermicidal gel being studied as a microbicide active againstSpermicidal gel being studied as a microbicide active againstHIV.HIV.DuetDuet -- Disposable diaphragm which will be preDisposable diaphragm which will be pre- -filled with BufferGel. It isfilled with BufferGel. It is

designed to deliver microbicide to both the cervix and vagina. Unlikedesigned to deliver microbicide to both the cervix and vagina. Unlikecurrently available diaphragms, the Duet is in only one size and will notcurrently available diaphragms, the Duet is in only one size and will notrequire a prescription, fitting, or a visit to a doctor.require a prescription, fitting, or a visit to a doctor.SILCS DiaphragmSILCS Diaphragm -- Silicone barrier (In clinical testing). It has a finger cupSilicone barrier (In clinical testing). It has a finger cupmolded on one end for easy removal. Like the Duet, the SIL C S will also bemolded on one end for easy removal. Like the Duet, the SIL C S will also beavailable in one size.available in one size.

A A vaginal ringvaginal ring is being developed that releases both estrogen andis being developed that releases both estrogen and

progesterone, and is effective for over 12 months.progesterone, and is effective for over 12 months.2 types of progestogen2 types of progestogen- -only vaginal ringsonly vaginal rings are being developed (Useful inare being developed (Useful inwomen who are breastfeeding). The rings may be used for four months at awomen who are breastfeeding). The rings may be used for four months at atime.time.

A A progesteroneprogesterone- -only contraceptiveonly contraceptive is being developed that would beis being developed that would besprayed onto the skin once a day.sprayed onto the skin once a day.Quinacrine sterilizationQuinacrine sterilization and theand the Adiana procedureAdiana procedure are two permanentare two permanent

methods of birth control being developed.methods of birth control being developed.

FEMALE


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C ONT R AC EPTIONC ONT R AC EPTION(Methods under Development)(Methods under Development)

M ALEM ALE

Adjudin : is currently in Phase II human trials as a male oral Adjudin : is currently in Phase II human trials as a male oralcontraceptive.contraceptive.

RISUG (

Reversible Inhibition of Sperm Under Guidance)

:

RISUG (

Reversible Inhibition of Sperm Under Guidance)

: Experimental injection into the vas deferens that coats the walls of Experimental injection into the vas deferens that coats the walls of

the vas with a spermicidal substance. The method can potentially bethe vas with a spermicidal substance. The method can potentially bereversed by washing out the vas deferens with a second injection.reversed by washing out the vas deferens with a second injection.

VasVas--occlusive contraception : It involves an implant placed in theocclusive contraception : It involves an implant placed in thevasa deferentia.vasa deferentia.

Experiments in heatExperiments in heat- -based contraception involve heating a man'sbased contraception involve heating a man'stesticles to a high temperature for a short period of timetesticles to a high temperature for a short period of time

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