Contraception - Updates

Mr. Wu Pin
Ms. Nur Sakinah
 Definition
• Methods or techniques to prevent pregnancy
as a consequence of sexual intercourse.
 Classification

Temporary Permanent
 Temporary methods
• Hormonal contraceptives
 Oral (Combined OCPs, POPs)
 Injectable -Depot preparations
 Implants Contraceptives
 Skin patches
 Vaginal rings
• Intrauterine contraceptive device (IUCD)
• Barrier devices(condoms, diaphragm , cervical swab, sponge)
• Fertility awareness methods (Natural methods)
 Temperature
 Calendar , cervical swab
 Symptom-thermal
 Permanent methods
• Male - Vasectomy

• Female - Tubectomy - Bilateral tubal ligation,

Laparoscopic Tubectomy,
Hysteroscopic procedure
Hormonal Contraceptives
1) Combined Oral Contraceptive Pills

Estrogen component (20-30micrograms):

Ethinyl Estradiol (EE)
Progestin component (3mg) :
Norethisterone,
Levonorgestrel,
Desogestrel,
Drosperinone
 Mechanism of Action
• Combined OCPs contains synthetic hormones that
are slightly higher dose than physiological level

Negative feedback on endogenous gonadotrophins

(FSH & LH)on HPA.

Prevents ovulation

• Progesterone - makes endometrium thin &

unfavorable for implantation
• Thickens cervical mucus to prevent entry of sperm
 Dosage
• 1st tablet to be started on day 1 of the
menstrual cycle
• Taken regularly daily for 21 days (preferably at
a fixed time daily)
 Drug interaction
• COCP mainly metabolized by liver enzymes
enter entero-hepatic circulation

• Metabolism by:
Anticonvulsants (except Sodium valproate)
Rifampicin
Griseofulvin
Broad-spectrum antibiotics
 Adverse effects

Minor Major
• Nausea • MI
• Breakthrough bleeding • Venous thrombo-embolism
• Breast tenderness • Malignancies
• Irregular cycles  Breast
• Amenorrhoea (2%)  Ovarian
 Endometrial
 Cervical
 Contraindications
• Pregnancy
• CVS women (previous thromboses/cerebral
hemorrhage, IHD,HTN)
• Pulmonary HTN
• Liver disease patient
• Cholestatic jaundice in pregnancy
• Hepatoma
• Diabetic women
• Any estrogen dependent tumour
 2) Progesterone only pill (Mini-Pill)
• Only progestin
• 28 days packs & all pills are active
• Must be taken at fixed time daily to maintain the
effectiveness
• MOA : Thickens the cervical mucus
• Indications:
1) Women >35yrs of age
2) Obese women
3) Chronic/heavy smokers
 3) Injectable contraceptives
• Depot Medroxyprogesterone acetate (DMPA
150mg) given IM injection once in 3 months
 Injectable contraceptives
Mechanism of Action:
 Decrease the pulse frequency of GnRH
 Thus , decrease the release of FSH & LH
 Inhibit follicular development & prevent ovulation
 Inhibit sperm penetration
 Inhibition of ovarian function causes endometrium
to become thin & atrophic Prevent implantation
 Advantages Disadvantages

• Suitable for breast • Weight gain

feeding mothers • Menstrual irregularities
• Suitable for women with • Abdominal cramps
valvular & complicated /discomfort
congenital heart disease • Fertility can de delayed by
• No increased risk of 10-12 months of last inj.
developing DVT, PE, • Shouldn’t be used for
Stroke, MI more than 2 yrs
• Minimal drug interactions
 Contraindications
• Multiple risk factors for arterial CV disease
• Current DVT /PE
• Migraine headache with aura
• Unexplained vaginal bleeding
• Acute liver disease, Liver tumor, cirrhosis of liver
• HTN
• IHD
• Unexplained vaginal bleeding
• h/o stoke
• Diabetes >20 yrs
• Hormonally sensitive tumor
 4)Implant contraception
• Insert a progestin containing rod under skin

The rod release the progestin into blood stream

 Implanon (Sub dermal)
• Single rod contains
68mg of Etonogestrel
• 4cm X 2mm
• Lasts for 3 yrs
• Not suitable for heavy
smoker women/DVT
 Advantages and Disadvantages
 Ideal for women who • May experience
cannot use estrogen- bruising, tenderness,
containing contraception swelling in the first few
 Increase compliance of days
patient
 Not affected by other • May cause irregular
medications periods for first few
 3 yrs duration cycles
 5) Contraceptive patch
• Patch applied on skin
• Release synthetic estrogen & progestin hormones
• 1st patch is applied on 1st day of period
• Effect of a single patch only last for 1 week
• 2nd patch is applied exactly after one week
• 3 patches are applied for 3 weeks continuously
• Then free of patch for 1 week
• At the end of 4th week, start apply the patches again
• Easy convenient but expensive and not very popular in
many countries
 6)Vaginal ring
• Flexible plastic (ethylene-vinyl acetate copolymer)
ring that release a low dose of a progestin and
estrogen over 3 weeks
• Can be self inserted into
vagina
• For 3 weeks period
• Then removal it for 1 week
• During which, the women
will experience menstruation
Non contraceptive benefits of
hormonal contraceptives
• Menorrhagia
• Dysmenorrhoea
• Mid-cycle pain
• Abnormal uterine bleeding
• Endometriosis
• Functional ovarian cyst
• Benign breast disease
• Ectopic pregnancy

• Acne & hirsutism

• Breast pain Drosperinone containing preparations
• PMS
 Emergency contraception
• A.k.a post-coital contraception /morning after pills
• Methods of contraception to prevent conception when
taken within a few days of sexual intercourse
• Can prevent unintended pregnancy
• Indications:
 Sexual assault/rape
 Incorrect use /failure of barrier methods(e.g Condom
slippage)
 IUCD expulsion
 Missing pills(>2 pills)
 Common EC Regimens & Dosage
EC Regimens Dosage
Levonogestrel(LNG) 1.5mg Single dose Within 0-72hrs
(LNG)0.75mg 2 tablets in 12hrs(within 0-120hrs)
Mifepristone 10-50 mg Within 0-120hrs
Yuzpe Within 0-72hrs
Cu IUCD Within 0-120 hrs
Combined OCPs(50microgran of EE+250 2 tablets to be taken 12 hrs apart
microgram LNG)
Intra-Uterine Contraceptive Device
(IUCD)
P
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Multiload 375
 Copper Releasing Progestin
Releasing (Mirena)
Examples: Cu T200 Levonorgestrel releasing
Cu T380A Intrauterine system
Multi-load Cu 250 (LNG-20 IUS)
Multi-load 375
Effectiveness: Cu T 200-remove 4yrs LNG 20-IUS-effective as
Cu T 380A-replace after 10 yrs contraception for 5 yrs
Multi-load Cu 25-replace after 3 yrs

Trade name: Mirena coil/LNG-20-IUS

MOA: -Ionized Cu prevents implantation
-initiates release of cytotoxic cytokines
-induce strong & uniform
suppression of endometrium
-scanty cervical mucous
-anovulation & insufficient
luteal phase
 Pre insertion counselling
• May be cause irregular PV bleeding (esp. 1st 3-
6months)
• Request for STDs screenings(e.g:Screen for
chlamydia prior to insertion)
• Expulsion risk(common in 1st 3 months after
insertion
• Perforation risk
• Increase risk of pelvic infection
• May cause dysmenorrhoea
 Timing of Insertion
• Can be inserted any time of the cycle but preferably
2-3 days after the Last menstrual period is over

• Lactation amenorrhea - any time

• Post partum: preferred after 6 weeks when uterus is

involuted to near normal size

• High rate of expulsion if inserted just after delivery

 Contraindications:
• Risk factor for STD
• H/o menstrual disorders (should avoid Copper
releasing IUDs)
• Acute pelvic infection
• Pregnancy
• Past h/o ectopic pregnancy
• Abnormal PAP smear
• Cervical/uterine cancer
• Anatomical abnormalities of the uterus
• Very large/very small uterus
 IUCD
Advantages
 Higher efficacy
 Long duration of action
 Safe effective & less A/E
 Increased compliance
 Intercourse can resume at any
time
 Cu releasing IUCD –has no
hormonal side effects
 Reduced risk of ectopic
pregnancy
 Mirena IUCD reduces
menorrhagia
Disadvantages
• Abdominal cramps, pain,
syncopal attack
• Partial/complete perforation if
insert by untrained personnel
• Menorrhagia & dysmenorrhoea
for 1st few cycles
• Ovarian cyst(that may resolve
on their own)
• Expulsion(2-8%) during
immediate postpartum period
 Indications for removal:
• Persistent uterine bleeding
• Flaring up salpingitis
• Perforation of uterus
• Partial expulsion
• Pregnancy with device in situ
• Missing threads
• 1 yr after menopause
 LARC (Long Acting, Reversible contraception)
• Implanon and IUCDs are highly effective because they do
not depend on compliance from the patient.

• Cu-T IUCD, and LNG- IUS

 Prophylactic antibiotics are not recommended for insertion
 Both methods tend to cause heavy and painful periods for
1st few cycles but normalizes after few months
 Should avoid IUCDs in active pelvic infection, unexplained
vaginal bleeding, endometrial Ca/Cervix Ca.
 LNG – IUS (Mirena)
• Has a T-shaped rod containing 52mg LNG
• Release 20 micrograms daily
• Reversible, highly effective contraceptive with a failure
rate of 0.18 per 100 women-yrs
• Advantages:
 Menstrual blood loss is decreased, so can be used in
the management of menorrhagia
 Used in patient with h/o breast cancer
 Breast-feeding women
• Disadvantages:
 Irregular PV bleeding(1st 3-4 months)
 Hormonal symptoms(nausea, headache, bloating)
 LARC
• Combination injectable contraception
Contain Medroxyprogesterone / estradiol
(25mg/5mg in 0.5ml Inj.)
Initial dose 0.5ml IM within 5 days of
menstrual cycle ; followed by 0.5ml IM every
28-30days(not more than 33 days between
injections
Barrier methods
• Barrier contraceptives are devices that provide a
physical barrier between sperm and egg fertilization.
• It can be in physical or chemical methods
• PHYSICAL
– Male condoms, female condoms, diaphragm, cervical cap,
sponge
– Condom provide no hormonal side effects
– Decreases cervical dysplasia and HPV-cervical cell
abnormalities
– It prevents sperm allergy ( rarely seen in some women),
useful in couple which coital activities is irregular or
infrequent
• CHEMICAL (Nonoxynol) as a spermicide, it attacks the acrosomal membranes of
the sperm, causing the sperm to be immobilized.
• BOTH PHYSICAL AND CHEMICAL METHODS
– Can prevent sexually transmitted infection (STI)
 Physical methods
Male condom :
• Efficacy is by the quality of products and adding
spermicidal agents
• Suitable : couple who wants spacing or have
infrequent sexual intercourse, contraindication of
OCP or IUCD use
• Advantages : cheaper, no contraindication, no
hormonal side effects, easy to use, disposable,
protection against STD, PID
• Disadvantages : may accidentally break or slip
during coitus, high failure rate
• Female condom - pouch made of poly-urethane
which lines the vagina and also external genitalia
(15cm)
• Flexible ring at each ends- inner and outer
• Inner end is smaller than outer rings
• Advantages : protection against STDs and PID
DIAPHRAGM
Fertility awareness methods
• Fertility awareness methods- natural methods
which relies on observing the changes in the body
that indicate fertility
• Methods include :
– Basal body temperature
– Cervical mucus
– Calendar rhythm method
– Symptothermal

 Exclusive breast feeding absence of menstrual

cycle for 6 months
• Basal body temperature :
– Special thermometer used
– Should be taken when just wake up in morning before taking any
hot drinks
– Principle : ovulation cause slight increase in body temperature.
Fertile 2-3 days prior to rise in body temperature (fertile window-6
days long, starts 5 days before ovulation and ends on day of
ovulation, because sperm can survive for 5 days after coitus, ova
survive only one day after ovulation)
– Disadvantages : not all women are fertile within that period of
time, woman who has longer or shorter menstrual cycles may have
different fertility times
• Cervical mucus
• Sample of cervical mucus by hands every day for at least one month to
record quantity, appearance, feel and physical signs
• 6 days prior ovulation, mucus is clear, elastic (due to estrogen)
• After ovulation, mucus is thick, sticy and opaque (due to progesterone)

• Calendar methods (rhythms method-least reliable)

• Keep a record of menstrual periods for 6-12months. Substract 18 days from
shortest and 11 days from longest previous menstrual cycles.
• Eg:
• Shortest cycle 26 days (minus 18 days, 8)
• Longrst cycle 30 days (minus 11 days, 19) abstain coitus from day 8 to day
19 of each cycle
• Symptothermal methods
• Temperature + cervical mucus + calendar methods + symptoms
• Most effective fertility awareness methods
• Symptoms : change in shape of cervix, breast tenderness, cramping
 Emergency contraception
(postcoital contraception)
• Also known as morning after pill
• Indications: a) unprotected intercourse
b) condom rupture
c) missed pill
d) sexual assault or rape
e) on teratogenic medication
 Levonorgestrel :
 Single tablet containing 1.5mg within 72hours of
exposure
Two tablets of levonorgestrel 0.75mg. 1st tablet within
72 hours. 2nd tablet after 12hours
 Yuzpe methods (easily available)
2 tablets containing 50 microgram EE and 0.25mg
levonorgestrel (1st tablet within 72 hours. 2nd tablet
after 12 hours)
• Cu T IUCD
• Insertion within 5 days prevent implantation

• Mifepristone
• Dose is 600mg
• WHO show that different dose of mifepristone 600mg, 50mg, 10mg equally
prevent pregnancy.
• Highly effective within 72 hours of exposure, also effective after 12-15days of
coitus

• Gestrinone
• Within 72 hours, 5mg of gestrinone 88.9% prevent pregnancy
• Effectiveness 10mg mifepristone = 10mg gestrinone
• No fetal adverse effects when failure of emergency contraception
Permanent methods
Vasectomy
Advantages:
- simple operative technique
- few immediate and late complication
- minimal failure rate (0.15%)
- minimal overall expenditure

Disadvantages :
- additional contraceptive protection is
needed 2-3 months after vasectomy
(10 ejaculations)
Complications:
- immediate : wound sepsis, scrotal
hematoma
- late : sperm granuloma, increased
sperm agglutinin, spontaneous
recanalization
 Tubectomy
• Type of permanent female sterilization:
- Laparoscopic sterilization
- Bilateral tubal ligation
- Hysteroscopic sterilization
• Proper counseling is important (procedure,
advantages, disadvantages, complication are
explained and consent must be obtained)
• Permanent and irreversible
Laparoscopic Tubectomy

By Fallope Rings
• Advantages :
– Associated pelvic and abdominal abnormalities is
detected
– Cosmetic advantages : small scar
– Minimal postoperative pain and discomfort
Minilaparotomy - Bilateral tubal ligation
• Bilateral tubal ligation is a surgical procedure that
involves blocking the fallopian tubes to prevent the
ovum from being fertilized.
• It can be done by cutting, burning or removing
sections of the fallopian tubes or by placing clips on
each tube.
• Generally referred to as “Minilap,” is an
abdominal surgical approach to the fallopian tubes
by means of an incision less than 5 cm in length
• Incision site : suprapubic and sub umbilical incision
 Hysteroscopic sterilization
Hysteroscopic sterilization is a type of tubal sterilization procedure that uses the
body’s natural openings to place small implants into the fallopian tubes. These
implants cause tissue growth that blocks the tubes. No surgical incision is needed
• Hysteroscopic sterilization involves inserting a tiny
device into each fallopian tube with a hysteroscope.
• The hysteroscope is an instrument that is inserted
through the vagina and cervix and then into the
uterus.
• It allows the inside of the uterus and the tubal
openings to be seen.
• Once the devices are in place, scar tissue forms
around them.
• It takes 3 month post operative to be effective
 Contraceptive choices for
different categories of women
Category Preferred method

1) 22yr old single career women Combined OCPs

2) Breast feeding housewife Depo-Provera Injection

3) 25yr old mother of 3 children LARC

4) 35yr old with menorrhagia LNG-IUS

5) 40yr old obese heavy smoker POP

6) Sex worker Barrier method

7) 45 yr old mother of 9 children Surgical sterilization

 Contraceptive Failures
• Pearl Index Method - No of failures in 100 woman
in a year (HMY)
• In 12 cycles in one year of a particular methods
No of pregnancies
Failure per HMY = ----------------------------- ----- × 1200
Total months of exposure

• Male condom : 10-14/HWY

• Combined OC pills : 1-3/HWY
• IUCD : 1-3/HWY
 References:

• Obstetrics today(2nd edition):pg 588-599

• Clinical Protocols in OBGs for Malaysian Hospital

Pages : 589-603