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Unintended pregnancy is a significant public health

About half of all unintented pregnancies end in abortion
In the US approximately 62 million women are of
childbearing age ( 15-44 years ) and approximately six
million become pregnant each year
Contraception commonly prevents the pregnancy and secondary
uses :
Heavy or irregular menstruation
Polycystic ovary syndrome
Dysfunctional uterine bleeding

Commonly used methods of reversible contraception, include :

Intrauterine devices ( IUDs)
Barrier methods :
Cervical caps
The menstrual cycle

The cycle of menstruation comprises three phases ( follicular,

ovulatory and luteal ( postovulatory )
The first day of menses is reffered to as day 1 of the
menstrual cycle ( the beginning of the follicular phase )
The median menstrual cycle length is range from 21 to 40
The menstrual cycle is influenced by the hormonal relationship,
among the hypothalamus, anterior pituitary and ovaries
The hypothalamus secretes GnRH
GnRH stimulates the anterior pituitary to secrete bursts of
gonadotropins, FSH,and LH
The gonadotropins FSH and LH direct events in the ovarian
follicles that result in the production of a fertile ovum
Hormonal Contraception

Hormonal contraceptives contain eiher a combination of

estrogen and progestin or progestin alone
Combined hormonal contraceptives (CHCs) work before
fertilization to prevent conception

Estrogen suppress FSH release from pituitary , which may

contribute to blocking the LH surge and preventing ovulation
Primary role in hormonal contraceptives is to stabilize the
endometrial lining and provide cycle control
Two synthetic estrogen found in hormonal contraceptives ,
ethinyl estradiol ( EE ) and mestranol
Mestranol must be converted by the liver to ethinyl estradiol
before it is pharmacologically active. It is 50% less potent than EE
Most combined OC s contain estrogen at doses 20 to 50 mcg of

Progestin is synthetic form of progesterone

Progestins provide most of the contraceptive effect :
o thickening cervical mucus to prevent sperm penetration,
o slowing tubal motility
o delaying sperm transport

Progestins used in OCs include desogestrel,

drospirenone, norgestrel, levonorgestrel, norethindrone,
norethindrone acetate, ethynodiol diacetate
Combined Hormonal Contraceptive

Combination OCs reduce the risk of ovarian cysts, ectopic pregnancy, PID,
and benign breast cancer
Estrogen excess cam cause nausea and bloating
Low dose estrogen CHCs can cause early or midcycle breakthrough bleeding
and spotting
Progestins associated with fatigue and changes in mood
Low dose progestin CHCs may cause late breakthrough bleeding and
Adverse effect of CHC
Hormonal Methods

Oral Contraceptives ( Birth Control Pill )

Vaginal ring
Mechanism action of the pill
Mechanism action of the pill

Stops ovulation
Thins uterine lining
Thickens cervical mucus
Types of pill contraceptives

Monophasic oral contraceptives :

Contain the same amounts of estrogen and progestin for 21 days, followed by 7
days of placebo pills
Biphasic and triphasic pills
Contain variable amounts of estrogen and progestin for 21 days, followed by 7 days
of placebo pills
Contain progestin only ( 28 days of active hormone per cycle )
Initiating an Oral Contraceptive

Ocs were initiated after the next menstrual period occurred,

several weeks after childbirth, or after a breastfeeding infant was
In the first 21 days postpartum, if contraception is required,
progestin only pills and IUDs are acceptable choices
Choice of Oral Contraceptive
Choice of Oral Contraceptive

Adolescents, underweight women , women older than 35 years and those who are
perimenopausal may have fewer side effects with OCs containing 20-25 mcg EE
Women with oily skin, acne, and hirsutism should be given low androgenic Ocs
Women with migraine headaches, history of thromboembolic disease, heart disease,
cerebrovascular disease, SLE, and hypertriglyceridemia are candidates for progestin
only methods
Women who are older than 35 years , smokers , or obese , have hypertension or
vascular disease should use progesterone only
Oral contraceptives side effects

Weight changes
Breast tenderness
Drug interactions with oral contraceptives
Oral contraceptives instruction

28 pill pack has 21 hormone pills. The seven pills are placebo to
help the user stay in the habit of taking a pill everday
Take a birth control pill at the same time everyday
Instruction for missed pills

1 active pill < 24 hours late in any week- take 1 active pill ASAP and
continue pack as usual
Missed 1 or more active [ills ( > 24 hours late ) :
If during week 1 :
Take 1 active pill ASAP and continue pack as usual-back up contraception
for 7 days
If during week 2 or 3 and missed < 3 pills :
Take 1 active pill ASAP and continue active pills as usual, but discard placebo
pills and start a new pack
If during week 2 or 3 and missed 3 pills :
Take 1 active pill ASAP and continue active pills as usual, but discard placebo
pills and start a new pack
Back up contraception for 7 days
Emergency contraception

Emergency contraception ( EC ) is used to prevent unwanted pregnancy

after unprotected sexual intercourse
Higher doses of combined estrogen and progestin or progestin only
containing products can be used
EC is taken within 72 hours of unprotected intercourse, the second dose is
taken 12 hours later
EC prevents the fertilized egg from implanting into the endometrium and
impaired sperm transport and corpus luteum function
Oral EC will not disrupt the fertilized egg after implantation has
Common adverse effect include nausea, vomiting, and irregular
Injection Contraceptive

Mechanism action : blocks the LH surge, thus preventing ovulation; thicken the
cervical mucus, producing a barrier to sperm penetration
Depo-Provera ( medroxyprogesterone acetate ) is administered by deep IM injection
within 5 days of onset of menstrual bleeding and inhibit ovulation for more than 3
These injection may inhibit ovulation for up to 14 weeks , the dose should be
repeated every 3 months
Adverse effect : breast tenderness, weight gain, menstrual irregularities
Subdermal Progestin Implants

Norplant implant
Vaginal ring

Vaginal ring contain EE and etonogestrel ( NuvaRing )

Over a 3 week period, the ring releases approximately 15 mcg/day of EE
and 120 mcg/day of etonogestrel
On the first cycle of use, the ring should be inserted on or before the fifth
day of the menstrual cycle
The ring should be inserted vaginally
Intrauterine device

Two IUDs currently marketed , are T shaped and one with

levonorgestrel ( mirena )
Disadvantage of Levonorgestrel IUD is increased spotting in the
first 6 months of use
Disadvantage of copper IUD is increased menstrual blood flow
and dysmenorrhea
Spermicide-Implanted Barrier Techniques

The vaginal contraceptive sponge contains the spermicide

Prevents pregnancy blocks the egg and sperm from meeting
Barrier methods have higher failure rates than hormonal methods due to
design and human error
Male condom

Most common and effective barrier method when used properly


Inserted up to 18 hours before intercourse and can be left in for a total of 24

Cervical cap

Latex barrier inserted in vagina before intercourse

Must be left in place six hours after sexual intercourse