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Contraception
Contraception
Important that women are able to plan timing of children Aim of contraception is to prevent pregnancies from occurring while causing the least amount of side effects to the patient
Types of contraception
Oral contraception- COCP, progestogen only pill Injectable- provera Implant- Implanon ( historically- Norplant) Intrauterine- IUCD, Mirena IUS Barrier contraception- condoms. Diaphragm Postcoital contraception Natural- rhythm method, coitus interruptus
EFFECTIVENESS
Dependent of motivation, regular usage, correct manner Assessed by Pearl Index
Number of pregnancies which occur in 100 women using that method for a year
COMBINED PILL
Oestrogen + progesterone Inhibit ovulation Not dependent on intercourse Additional advantages Disadvantagecompliance is needed Pearl index 0.1-1.5
COMBINED PILL
Commonest regime
Start on day 1 of a cycle; a pill is taken each day for 21 days; then 7 days pill free
COMBINED PILL
What to do if forgotten to take the pill?
<12 hrs <12 hrs
Take most recent delayed pill. Discard earlier missed pills Use extra precaution for next 7 days How many more pills left?
7 pills or more
< 7 pills Start the next pack immediately after Finishing with the old pack
PROGESTOGEN ONLY
Continuous daily Pearl index 1.5-3.0 Act by increasing viscosity of cervical mucus Breakthrough bleeding No risk of VTE Can be use during lactation
Depo-provera
Depo-medroxyprogesterone acetate Given as 1 injection every 12 weeks Inhibits ovulation at that dose and after 1 year of usage 80% are either amenorrhoeic or have scanty infrequent periods 20% may still present with irregular bleeding episodes
Side effects
Weight gain A delay in the resumption of fertility can occur for up to 1 year Small reduction in bone density
IM DEPO
Slow-release, long acting Progesterone, intramuscular Interval 1-6 months Depo-provera, norethisterone IM Depo-Provera 150mg 3-monthly-----Pearl index 0.5-1.5 Independent on intercourse / patients memory
Headache Nausea Facial pigmentation Fluid retention Weight gain Breast tenderness Breakthrough bleeding
IM DEPO
Benefit in
Dysmenorrhoea Menorrhagia Premenstrual symptoms Lactation, no effect on BP / VTE risk of CA endometrium 5-fold
Side effects
Irregular uterine bleed Amenorrhoea Weight gain Delay return in fertility of 6 months
SYSTEMIC CONTRACEPTION--SPECIFIC SITUATIONS Hypertension Metabolic effects Hepatic function Carcinogenic Dysmenorrhoea Lactation Surgery Drug interaction
Intrauterine Devices
Benefits
Does not require a person to take medication Good for those with a contra-indication to taking oestrogen Useful for patients who are not compliant to taking medicines ( but be careful of risk of pelvic infections)
IUD
Insertion-exclude contraindication Renewal 3-5 years Removal by pulling the tail Pearl index <3 Side effects
Pain Menstrual loss Expulsion <3% Uterine perforation 1 in 1000 Salpingitis 1.5-7.5 per 1000 Endometritis
IUCD
Mild inflammatory reaction in endometrium Previously: loop, ring, spiral coil, T, 7 Now:
Multiload, NovaT Copper-inhibit implantation, spermicidal Gynefix Mirena-levonogestrel
Intrauterine System
Mirena
Contained levonogestrel 52mg For 5 years Reduction of menstrual loss by 97% after 12 months Can be used with HRT as endometrial protection
Implants
Implanon
Uses Etonogestrel Lasts up to 3 years
Effective
Irregular bleeding (compare with norplant)
Barrier Methods
CONDOM
Most widely used in UK Simple Should be used with a chemical spermicide added security Pearl index 4-10
CONDOM
Benefit
risk of venereal infection Controlling the spread of HIV
Failure
Defective of the sheath Require emergency contraception
SPERMICIDE
Chemical substance placed in vagina before intercourse Pessaries, creams, aerosol, foaming tablets Poor result when use on their own Side effectsoreness / irritation
Natural Methods
COITUS INTERRUPTUS
Withdrawal of penis before ejaculation Pearl index 20-30 Failure due to
Delay withdrawal Presence of sperm in the pre-ejaculatory fluid
RHYTHM METHOD
Permitted by the Roman Catholic faith Pearl index 20-30 Assumption
The ovum is only capable to be fertilized in 24 hrs Sperm can only fertilize ovum in 72 hours
RHYTHM METHOD
Not suitable for irregular cycles Monitor cycles for 1 year Deduct the shortest cycle with 18 Deduct the longest cycle with 11 Example:
Cycle 26-32 days 26-18=day 8; 32-11=day 21 Day 8-21 will be fertile period
BODY TEMPERATURE
Ovulation -------basal body temperature Avoid intercourse for the next 72 hours Pearl index 5-7
Sterilisation
TUBAL OCCLUSION
Laparotomy / laparoscopy / colpotomy Ligate / diathermies / clip / ring Preferred to be performed 6 weeks postpartum Anaesthetic risk Failure 1-2 in 1000
VASECTOMY
Simpler & safer than tubal occlusion Not immediately effective Complications:
Hematoma infection
Breastfeeding delay return of fertility The delay dependent of frequency & duration of BF episodes Criteria
Fully / near fully BF Amenorrhoeic
Chance of pregnancy within 1st 6 months is <2%
Emergency Contraception
EMERGENCY CONTRACEPTION
Yuzpe regime:
100g EE, 500g levenorgestrel BD Within 72 hours Failure rate 3.2%
Prostinol
750g levonorgestrel BD Failure rate 1.1% Fewer side effects
Copper IUD
Within 5 days Most effective
Conclusion
There are many forms of contraception available Important to know the advantages and disadvantages of these options Useful to see what is being advised for our post-natal patients and relate the types of contraception recommended with each individual patient