1. IUD DEVICES FAMILY PLANNING 3.

LONG A
Copper T380A intrauterine device TIER 1 METHODS: HIGHLY EFFECTIVE  FIRST LINE CONTT
 Paragard  Fewer than 1 pregnancy per 100 women in 1 year  Long acting reversib
 T-shaped device of polyethylene wrapped with copper wire around the  INTRAUTERINE DEVICES (IUDs)  These methods requ
stem and arms  IMPLANTS use
 FDA has approved use of the copper IUD for up to 10 continuous years  LARCS  LARC methods are
 failure rate at 1 year of 0.8 per 100 women  MALE AND FEMALE STERILIZATION rapid return to fertilit
 1.9 per 100 women over 10 years IUD DEVICES: PAIN DURING INSERTION  LARC methodS offe
 Mechanism of action: preventing fertilization through inhibition of sperm  Cervical preparation with misoprostol does not increase the success of  The LARC methods
migration and viability insertion and increases pain.  a single-rod e
 Copper markedly increases the extent of the inflammatory  Ibuprofen administered prior to insertion does not reduce insertion pain  the Copper T
reaction throughout the uterine lumen and penetrate the cervix but may be helpful for the cramping that occurs in the hours immediately  levonorgestre
and probably the fallopian tubes. following insertion
 sperm cannot reach the egg  If a narrow cervix prevents the passage of a uterine sound, a
 Cu ions act on the cervical mucus to create a spermicidal effect paracervical block should be placed and dilation performed.
___________________________________________________________ CONTRAINDICATIONS OF IUDS
Levonorgestrel-Releasing Intrauterine Devices •IUDs not be inserted into women with any of the following:
 Levonorgestrel (LNG) is a synthetic progestogen similar to Progesterone •pregnancy or suspicion of pregnancy  VASECTOMY is a s
 Examples: •acute PID  The vas deferens is
 LNG-20 IUD (Mirena) releases 20 micrograms/day; FDA approved for •postpartum endometritis or infected abortion  This occlusion of the
up to 5 years of use.Available in the Philippines •known or suspected uterine or cervical malignancy  low cost (it
 LNG-13.5 IUD (Skyla) 13.5 mg of levonorgestrel, releasing 14 •genital bleeding of unknown origin methods) a
micrograms/day FDA approved for up to 3 years of use •previously inserted IUD that has not been removed anesthesia
 Mechanism of action •women with certain liver diseases generally should not use the LNG-IUD  It does not
 profound change in the amount and viscosity of cervical •women with current breast cancer should not use the LNG-IUD easily verifi
mucus, making it impenetrable to sperm
Examinations and Tests Before Initiation of a Cu-IUD or an LNG-IUD 2. CONTRACEPTIVE IMPLANT
 Bimanual examination and cervical inspection  Contraceptive implant is placed SUBDERMALLY and contains 68 mg of  cutting or occluding
 baseline weight and BMI measurement etonogestrel surrounded by an ethylene vinyl acetate copolymer skin sperm and egg
 STD  Ethylene vinyl acetate copolymer allows for controlled release of  failure probability of
TIMING etonogestrel over 3 years TRANSABDOMINAL
 The IUD can be safely inserted in any of the following scenarios:  Contraceptive implant is the most effective method of reversible  Tubal occlusion can
 on any day of the cycle provided the woman is not pregnant contraception, with a typical-use pregnancy rate of 0.05% postpartum through
 immediately postabortion  MOA: still enlarged
 immediately postpartum following either vaginal or cesarean section  ligation and resectio
delivery technique such as th
 Copper IUD can be used as emergency contraception for up to 5 days
following unprotected intercourse. LAPAROSCOPIC AP
 Cu-IUD can be inserted within the first 7 days, including immediately  General anesthesia
postabortion.  Most common techn
 Cu-IUD should not be inserted immediately after septic abortion clip, and the Silastic
ADVERSE EFFECTS OF IUDS SIDE EFFECTS:Head aches, Sore throat, Vaginitis. Wt gain. Irregular
TRANSCERVICAL AP
Uterine Bleeding bleeding, ACNE, breast pain, abdominal pain.
 Sterilization using th
Perforation
microinsert device tr
Complications Related to Pregnancy COMPLICATIONS UPON INSERTION: pain, hematoma formation, slight
bleeding, deep or incorrect insertion, unrecognized noninertions, Branches  Device is placed in t
Infection in the Nonpregnant IUD User the device causes ti
of medial antebrachial cutaneous nerve injury.
 1. INJECTIBLE SUSPENSIONS FAMILY PLANNING ORAL CONTRACEPTIVE
(1.1)DEPO-PROVERA, OR DEPO-MEDROXYPROGESTERONE ACETATE TIER 2 METHODS: VERY EFFECTIVE EXTENDED CYCLE REGIMEN
 DMPA is in a dose of 150 mg intramuscularly (IM) or 104 mg
subcutaneously (SC) every 3 months
 When used correctly and consistently, the chance of pregnancy is 0.2%
 IM formulation is given by injection deep into the gluteal or deltoid muscle
 SC formulation is injected into the subcutaneous tissue of the anterior
thigh or abdominal wall
 Resumption of ovulation is delayed on average for 6 months and as long
as 1 year after a single injection
MECHANISM OF ACTION
 Inhibits ovulation: high levels of estrogen and progestin may supress
the FSH and LH and prevent them from being released by the pituitary
gland in the brain thus inhibiting the ovulation.
 Thickens the cervical mucus: levels of progestins may thicken the
cervical mucus making the sperm migration difficult.
 Prevents the normal build-up of the endometrium: does not allow the
normal build-up of the endometrial lining of the woman’s uterus. Thus, if
conception occurred, the newly conceived baby tries to implant but does
not find enough nourishment to remain in the uterus for the rest of the
pregnancy. This is the abortificient effect of the methods.
COMMON SIDE EFFECTS
 Irregular menstrual bleeding  Weight gain
 Termination of periods  Delayed return of fertility
 Bone density loss  Local injection reactions
NONCONTRACEPTIVE HEALTH BENEFITS
 DMPA reduces the risk of developing iron deficiency anemia and PID
 The reduction in risk of endometrial cancer in women on DMPA is long
lasting and substantial
 DMPA also reduces the incidence of primary dysmenorrhea, symptoms
of endometriosis, ovulation pain, and functional ovarian cysts because it
inhibits ovulation
CLINICAL RECOMMENDATIONS
 DMPA can be started at any time during the menstrual cycle as long as
the woman and her provider are reasonably certain that she is not
pregnant
 If given later than 7 days into the menstrual cycle, backup contraception
should be used for 7 days.
 Started 5 days postpartum for non-lactating women.
 At least 6 weeks postpartum for exclusively breastfeeding
 If pregnancy occurs in a woman receiving DMPA, the hormone does not
adversely impact the pregnancy.
(1.2) NORETHINDRONE ENANTHATE
 NET-EN – injectable progestogen
 Given every 60 days for the 1st 6 months and no less than every 12
weeks thereafter.
 WHO – given no shorter than 46 days and no longer than 74 days
ORAL CONTRACEPTIVES
 6 to 12 pregnancies per 100 women in 1 year)
 Injectables
 Pills
 Patch
 Ring
(1.3) PROGESTIN-ESTROGEN INJECTABLE FORMULATION
 Northisterone enanthate 50 mg + Estradiol valerate 5 mg – Mesigyna
 Regular withdrawal bleeding
 Ovulation inhibition
 Given between 1-5 days after onset of menses
 Given once a month (285 days).
 Deep IM – deltoid, anterior thigh, gluteal muscle
2. ORAL CONTRACEPTIVES
 Most widely used method of reversible contraception among both
married and unmarried women
 The major effect of the progestin component is to inhibit ovulation, but
progestins also contribute other contraceptive actions such as thickening
of the cervical mucus and thinning of the endometrium
 The major effects of the estrogen are to maintain the endometrium and
thus prevent unscheduled bleeding as well as to inhibit follicular
development through a synergistic effect with the progestin
 OCs have a 1% failure rate with perfect use and an 8% failure rate with
typical use
PHARMACOLOGY
 Three major types of OC formulations include daily
 progestin-only pills (POPs), also known as minipills
 fixeddose (monophasic) combination pills
 multiphasic combination pills
 Most oral contraceptive regimens: packaged in a 28-day (4-week) cycle
 OC formulations provide active pills continuously for 21 days (3 weeks)
followed by a 7-day hormone-free interval (HFI)
 OR provide active tablets for 24 days, reducing the HFI to only 4 days,
and these may be more effective than 21-day active pill formulations
PROGESTIN-ONLY PILLS (POPS)
 Minipill formulations consist of tablets with low dose of progestin and no
estrogen
 They are taken every day without a steroid-free interval.
FIXED DOSE (MONOPHASIC) COMBINATION PILLS
 Monophasic products contain tablets with the SAME dose combination of
an estrogen and progestin each day
MULTIPHASIC COMBINATION PILLS
 Multiphasic formulations, pills containing several different dose
combinations come in the same pack
 A different tablet color corresponds to each dose
FAMILY PLANNING
 Extended cycle regimens contain 84 days of active pills followed by a 7-
dayHFI (or 7 days of EE only) that results in withdrawal bleeding only
four times a year.
CONTINUOUS CYCLES
 continuous daily LNG 90-μg /EE 20-μg regimen with 28 active pills in a
treatment pack was introduced in 2007 to completely eliminate scheduled
withdrawal bleeds
 Withdrawal Bleeding
 •Uterine bleeding occurs secondary to hormone withdrawal during
the HFI, typically 1 to 3 days after taking the last active pill.
 •withdrawal bleeding usually lasts 3 to 4 days and is generally
lighter than during menses in an ovulatory cycle.
WITHDRAWAL BLEEDING
 Uterine bleeding occurs secondary to hormone withdrawal during the
HFI, typically 1 to 3 days after taking the last active pill.
 Withdrawal bleeding usually lasts 3 to 4 days and is generally lighter than
during menses in an ovulatory cycle.
BREAKTHROUGH BLEEDING
 Bleeding that occurs during the time that active pills are ingested.
MECHANISM OF ACTION
 Progestogen: negative feedback at the hypothalamus decreases the
pulse frequency of GnRH. This, in turn, will decrease the secretion of
(FSH) and decreases the secretion of LH. If the follicle isn’t developing,
then there is no increase in the estradiol levels (the follicle makes
estradiol). The progestogen negative feedback and lack of estrogen
positive feedback on LH secretion stop the mid-cycle LH surge. With no
follicle developed and no LH surge to release the follicle, there is the
prevention of ovulation.
 Estrogen has negative feedback on the anterior pituitary with slows FSH
secretion; it’s just not as prominent as the progesterone’s effect.
 Progesterone’s ability to inhibit sperm from penetrating through the cervix
and upper genital tract by thickening the mucus.
 Progesterone induced endometrial atrophy should deter implantation
COAGULATION PARAMETERS
 Screening for coagulation deficiencies should only be performed before
starting OC use if the woman has a family history of thrombotic events.
 Obesity is a modest risk factor for VTE, and extreme obesity (e.g., a body
mass index [BMI] >40) should be considered a relative contraindication
to use of a combined hormonal method.
 Use of OCs by women older than age 35 who also smoke is
contraindicated due to the risk of myocardial infarction.
RETURN TO FERTILITY
 •After discontinuation of low-dose OCs, the suppressive effect on the
hypothalamic-pituitary-ovarian axis disappears quickly
COMMON SIDE EFFECTS
Headaches
Breast tenderness
Nausea
Bleeding between periods
BARRIER METHOD
NEOPLASTIC RISKS AND BENEFITS
 Breast cancer- increases the risk of breast cancer by 25%
 Cervical Cancer- There is no evidence that OC use alters the incidence or rate
of the progression of cervical dysplasia to invasive cancer.
 Endometrial cancer- strong protective effect between OCs and endometrial
cancer
 Ovarian Cancer- reduce the risk of developing ovarian cancer.
 Liver Adenoma and Cancer- increased risk of this tumor was reported in
prolonged use of high-dose formulations
 Colorectal Cancer- decreases the risk of developing both colon and rectal
cancer
NONCONTRACEPTIVE HEALTH BENEFITS
 Long-term reduction in risk of ovarian and endometrial cancer, some of the
immediate benefits of OC use include improvement of menorrhagia and
dysmenorrhea and decreased acne
 prevent iron decifiency anemia
 OC users are significantly less likely to have menorrhagia, irregular
menstruation, or intermenstrual bleeding.
 As OCs inhibit ovulation, they can reduce such ovulatory disorders as
dysmenorrhea and premenstrual syndrome.
RELATIVE CONTRAINDICATIONS
 Pregnancy and Delivery (after < 3weeks)
 Lactating mother (<6 mos)
 VTE, SLE, or DM
 Heavy smokers <35 years old (<15 sticks/day)
 Migraine headache with aura over the age 35
 Undiagnosed cause of amenorrhea
 Clinical depression
 Controlled hypertension (140-159/90-99 mm Hg) and heart disease
 Mild cirrhosis
 History of OC related cholestasis
 Taking meds that may interfere with OC metabolism
BEGINNING ORAL CONTRACEPTIVES
 Pubertal girl who has demonstrated maturity of the HPO- axis with presumably
ovulatory menstrual cycles can begin OCs.
 Delivered after 28 weeks and are not nursing, the combination pills should be
initiated no sooner than 6 weeks after delivery.
 Early abortion ( <12 weeks ) – start immediately
 After 21 to 28 weeks – 1 week later
 >28 weeks and not nursing – 2 to 3 weeks after delivery
FOLLOW-UP
 After 3 months – History and BP
 No lab tests needed unless for routine health maintenance
 After 1 year – History, BP, body weight, PE
 Pap smear
 If with history of MI – lipid profile before OC use
 If with history of DM or GDM – 2hr postprandial glucose det.; or do OGTT
 If with history of liver disease – get liver panel
3. PERIODIC ABSTINENCE, COITUS-RELATED METHOD
TIER 2 METHODS: VERY EFFECTIVE 1.2 MALE AND FEMALE CONDOM
 6 to 12 pregnancies per 100 women in 1 year)  The latex and polyurethane male condoms are the only method with
 Injectables FDA-approved labeling that supports use of the product to prevent both
 Pills pregnancy and the transmission of sexually transmitted infections
 Patch  When used by strongly motivated couples, the male condom is effective.
 Ring The typical use failure rate is around 15%
 The female condom consists of a soft, loose-fitting polyurethane sheath
3. CONTRACEPTIVE PATCH with two flexible rings.
 Contains 75 μg ethinyl estradiol and 6 mg norelgestromin 2. LACTATIONAL AMENORRHEA METHOD (LAM)
 One patch is applied to the skin each week for 3 consecutive weeks  Prolactin inhibits gonadotropin pulsatility, nursing women typically remain
and no patch for the following week of a 4-week cycle to allow amenorrheic
withdrawal bleeding.  The criteria for successful use of LAM are continuous amenorrhea and
 The patch may be applied to one of four anatomic sites: buttocks, exclusive breast-feeding (no supplements) for up to 6 months after
upper outer arm, lower abdomen, or upper torso excluding the delivery
breasts  The failure rate in the first 6 months postpartum is less than 2%.
 Efficacy slightly lower in women with body weight more than 90 kg.
4. VAGINAL RING 3. PERIODIC ABSTINENCE, COITUS-RELATED METHOD
 A flexible ring-shaped device containing 2.7 mg of ethinyl estradiol  Many motivated couples use abstinence from sexual intercourse or a
and 11.7 mg of etonogestrel barrier method during the days of the menstrual cycle when the ovum
can be fertilized, or during the 5 days preceding ovulation or the day of
 Placed in the vagina for 21 days and then removed for up to 7 days
ovulation
to allow withdrawal bleeding.
 Calendar rhythm method
 Steroids pass easily through the vaginal epithelium directly into the
 Cyclic physiologic changes
circulation
 The cervical mucus method
 Steroids act systemically, the ring comes in only one size and does
 Sympothermal method (STM)
not have to be fitted or placed in a certain location.
 Mechanism of action is inhibition of gonadotropins and prevention CALENDAR RHYTHM METHOD
of ovulation  Pperiod of abstinence is determined by calculating the length of the
individual woman’s previous menstrual cycle and makes three
TIER 3 METHODS: EFFECTIVE
assumptions:
 Effective (18 or more pregnancies per 100 women in 1 year) 1. The human ovum can be fertilized for only about 24 hours after
 BARRIER METHODS ovulation
 LACTATIONAL AMENORRHEA 2. sperm can fertilize for 3 to 5 days after coitus
 PERIODIC ABSTINENCE, COITUS-RELATED METHODS 3. ovulation usually occurs 12 to 16 days before the onset of
1. BARRIER METHODS menses.
1.1) DIAPHRAGM AND CERVICAL CA  The woman therefore establishes her fertile period by subtracting 18
days from the length of her previous shortest cycle and 11 days from her
 The diaphragm is a thin, dome-shaped membrane of latex rubber or
previous longest cycle and abstains from coitus during this time
silicone with a flexible spring modeled into the rim
 Cyclic physiologic changes:
 A cervical cap is a cup-shaped silicone or rubber device that fits
around the cervix  Increasing levels of progesterone occurring after ovulation cause
a detectible rise in daily basal body temperature.
 The diaphragm and cervical cap should be used with a spermicide
and be left in place for at least 8 hours after the last coital act.  The woman must abstain from intercourse from the cessation of
menses until the third consecutive day of elevated basal
temperature, or when she is postovulatory
FAMILY PLANNING EMERGENCY CONTRACEPTION
CERVICAL MUCUS METHOD
 Requires that the woman recognize and interpret the presence and
consistency of cervical mucus.
 Increasing estradiol levels increase the production of cervical mucus
 Intercourse can occur after menses ends until the first day that copious,
slippery mucus is observed to be present and again 4 days after the last day
when the characteristic mucus was present
SYMPOTHERMAL METHOD (STM)
 Calendar calculation and change in cervical mucus estimate the onset of fertile
period
 Change in cervical mucus or basal temperature to estimate its end plus other
symptoms (breast changes, dull, lower abdominal pain, mid-cycle spotting),
and calculations that indicate ovulation.
 Abstinence from any form of contact until after the thermal shift of the peak
mucus symptom is observed; whichever comes first.
3. PERIODIC ABSTINENCE, COITUS-RELATED METHOD  Also known as the morning after pills.
COITUS-RELATED METHODS  Allows women to prevent pregnancy after an act of unprotected
 Spermicides intercourse
 The active agent is a surfactant that immobilizes or kills sperm  EC can actually be used up to 120 hours
on contact by destroying the sperm cell membrane.  Yuzpe method uses various forms and doses of combined OCs that
 Spermicides must be placed into the vagina before each coital prevent pregnancy after intercourse by inhibiting ovulation.
act, often in combination with a barrier contraceptive to increase  Yuzpe method involves one dose of one to six OC tablets, depending
effectiveness. on the brand, with a second dose 12 hours later
 Effective for 24 hours  Reduces the pregnancy risk by about 75%
 Coitus Interruptus (Withdrawal)  Most dedicated EC medications contain the progestin levonorgestrel
 Removal of the penis from the vagina prior to ejaculation to prevent  1.5-mg levonorgestrel single dose pill or two 0.75-mg pills given 12
pregnancy is an ancient male-controlled method of contraception hours apart, both to be given within 72 hours from the time of
without contraindications, devices, or cost unprotected sex.
 Delaying or inhibiting ovulation
EMERGENCY CONTRACEPTION
 Newer type of EC is a 30-mg single dose of the selective progesterone
 Copper IUD receptor modulator ulipristal acetate
 most effective form of EC.  Ovulation is delayed for 5 days in women who take ulipristal
 Insertion up to 5 days after unprotected intercourse is 99% acetate.
effective at preventing pregnancy.  120 hours from the time of unprotected intercourse, and it is 42%
 Danazol more effective at preventing pregnancy
 Epostane
 4 tabs ethinyl estradiol 0.05 mg + 2 tabs dl norgestrel 0.5 mg every
12 hours x 2 doses