Reminders:  Please  check  the  manual  for  the  ILO’s  for  this  topic.  The  Pink  boxes  are 
from  the  book  and/or  a  trans  from  the  previous  batch.  Gyne  Pearls/Key  points  and  TWO GENERAL TYPES OF FAMILY PLANNING 
Sample  Exam  questions  ​may  be  provided  at  the  end  of  the  trans​.  Enjoy and have fun 
studying!   1. Reversible Method​: temporary prevention of fertility and 
includes all the currently available contraceptive methods 
PART 1: CONTRACEPTION OVERVIEW 
★ The  ability  to  reproduce  or  fertility  is restored once 
● We  are  going  to  look  at  the  different  methods  of  the method is discontinued. 
contraception:  ○ Spermicides 
○ How they work  ○ Barriers 
■ Mechanism of Action (MOA)  ○ Hormonal Methods 
○ What are their advantages and their disadvantages  ■ Oral Contraceptive Pills 
■ Clinicians should be able to explain the  ■ Long-acting  Hormonal 
unique features of each method.  Contraception 
■ Evaluate  whether  medical  ○ Intrauterine  devices  or  Intrauterine 
contraindications  to  a  particular  method  systems 
exist  for  a  woman  and  offer  her  safe  and  2. Permanent​ ​Method​: terminal 
effective alternatives.  ★ Entails minor procedures  
■ The  Health  risks  associated  with  ★ Although  these  are  considered  permanent, 
unintended pregnancy  nowadays  we  have  the  ability  to  re-anastomosis  of 
● The  best  method  for  an  individual  is  ​one  that is relatively  ligated  tubes  or  vas  deferens.  But  the  success  rate 
safer  than  pregnancy  and  that  will  be  used  correctly  and  for future pregnancies will be at 50% (at best) 
consistently  ○ depend on the extent of damage and  
○ the skill of the surgeon 
● Seventy  percent  of  the  64  million  U.S.  women  aged  15  to 
★ For the females: ​BILATERAL TUBAL LIGATION 
44 are at risk of unintended pregnancy.  ★ For the males: ​VASECTOMY 
● Half  of  pregnancies  in  the  United  States  are  unintended, 
and  among  women  who  experience  unintended  CONTRACEPTIVE EFFECTIVENESS 
pregnancy, more than half are not using contraception. 
➔ These  are  the  various  indices  which  reflect  or  show  the 
● The  ​most  common  methods  are  the  oral  contraceptive 
effectiveness  of  each  method,  using  these  we may be able to 
pill  (16%),  female  sterilization  (15.5%),  condoms  (9.4%), 
compare and rank them.  
long-active  reversible  contraception  (LARC)  (7.2%),  or 
➔ Represent effective of each method 
intrauterine devices (IUDs) and implants.  
● Typical Use Effectiveness 
○ Overall  rate  of  effectiveness  in  actual  use  of  a 
particular  contraceptive  method  taking  into 
consideration human errors 
○ Factors  in  the  common  errors  from  using  each 
method 
● Perfect Use Effectiveness 
○ The rate of effectiveness of a contraceptive when it 
is always use correctly and consistently 
○ No factor of the user error 
○ Method itself, not reflective of actual use 
● Contraceptive Failure Rate 
○ Pregnancy rates with various types of 
contraceptives at different intervals or years. 
○ Number of pregnancies per 100 women at 1 year 
 
● Pearl Index 
Additional Notes: 
○ Pregnancy rate computed at ​Number of 
● In the Philippines, giving birth KILLS.  
pregnancies x 1200 over woman months of use 
● Maternal mortality rates for women 15-49 years old is at 
19.8%.  ★ All contraceptive methods have a typical use 
● Neonatal, infant, child, and under-five mortality rates are  effectiveness and perfect use effectiveness 
at 14%, 8%, 22% and 8% respectively.  ★ Pregnancy rates can vary widely between typical and 
  perfect use depending on how complicated it is to use a 
Family  Planning  as  defined  in  the  ​RA  10354:  An  Act  Providing  for a  method perfectly 
National  Policy  on  Responsible  Parenthood  and  Reproductive  ★ Remember​ the following:  
Health  ○ Coitus-related  methods  and  more 
● Enables  couples  and  individuals  to  decide  freely  and  user-dependent  methods  are  less  effective  than 
responsibly the number and spacing of their children  “forgettable methods” such as LARC. 
● To have the information and means to do so  ○ Use  of  two  methods,  or  “dual  method  use,” 
● To  have  access  to a full range of safe, affordable, effective,  provides added contraceptive protection 
non-abortifacient  modern  natural  and  artificial  methods  ○ Combining  a  hormonal  method  with  a  condom 
of planning pregnancy  provides  the  additional  health  benefit  of 
 
1/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
■ If  repeated  intercourse  takes  place, 
reducing sexually transmitted infection. 
additional  spermicide  should  be  used 
  vaginally 
■ According  to  Dra:  4-6  hours  after 
REVERSIBLE METHODS  ejaculation  and  never  not  more than 24 
  hours! Do not forget to remove it. 
● It  can  induce  ulcerations  in  the 
I. Spermicides  vaginal  mucosa  ​and  this  can  be 
● These can either be in gels, foams and suppositories   a nidus for infection.  
● The active ingredient or agent found in these methods are all  ● Advantages​: 
the same: ​NONOXYNOL-9  ○ Safe, reversible 
● Coitus-related:  ○ Married, motivated women 
○ Used on/applied only at the time of coitus/sex.   ○ Failure rates decrease with age and duration of use 
○ If you apply them long before or after, the coital act  ■ During  the  first  year  of  use  for  the 
are relatively ineffective  diaphragm  ranges  from  13%  to  17% 
○ Duration of action of Nonoxynol-9: Few hours only  among  all  users  and  may  be  as low as 4% 
(24 hours only)  to 8% with perfect use. 
○ Failure rate: 15-25%  ● Adverse Effects: 
● Used in conjunction with barriers (like condom)  ○ Urinary tract infections 
○ To INCREASE its effectivity  ○ Vaginal epithelial ulcerations 
● Adverse effects:  ● How is it used? 
○ Nothing much here  ○ Upright position with one of the leg slightly raised  
○ In  fact,  if  the  pregnancy  ensues  and the spermicide  ○ After  applying  the  spermicide,  place  it  on  the 
fails  to  prevent  conception,  the  neonate  has  no  highest  part  of  the  vaginal  canal  fitting  opposed  to 
increased  risk  for  congenital  malformations  or  the cervical fornices 
chromosomal anomalies.   ○ If small, gets dislodged.  
● How is it used?  ○ If  large,  obstruction  symptoms  and  ulcerations 
○ Put the spermicide on your finger and insert it in the  might happen 
vaginal  canal  and  place  it  high  in  the  vagina  near  2.Cervical Cap 
the vicinity of the cervical os. 
○ More  sanitary:  when  it  comes  with  a  syringe  ● Smaller compared to the Diaphragm barrier method.  
apparatus or applicator   ● Literally like a bottle cap applied over the cervix 
 
II.Barrier Methods 
● It is a cup-shaped silicone or rubber device that fits around 
● These are the 4 types of barrier methods: Diaphragm, Cervical  the cervix. It should be fitted to the cervix by a clinician. 
Cap, Male Condom and Female Condom   ● The only cap currently on the U.S. market is the FemCap. 
○ This  product,  made  of  soft,  durable, 
1.Diaphragm 
hypoallergenic,  silicone  rubber,  is  designed  to 
● It  is  a rubber cup and the CONCAVE portion is where we place  contact  the  vaginal  walls  as  the  dome  of  the 
the spermicide and it is then opposed on the cervix.   device sits over the cervix 
 
 
A  ​thin,  dome-shaped  membrane  of  latex  rubber  or  silicone  ​with  a  ● There are three sizes, should fit perfectly 
flexible  spring  modeled  into  the  rim  The  spring  allows the device  ○ Small: 22mm 
to  be  collapsed  for  insertion  and  then  allows  for  expansion  within  ○ Medium: 26mm 
the  vagina  to  seat  the  rim  against  the  vaginal  wall,  creating  a  ○ Large: 30mm 
mechanical barrier between the vagina and the cervix.  ● The premise is the same like in the Diaphragm method.  
● The  spermicide  is  also  placed  on  the  concave  portion  of  the 
 
● The  objective  here  is  to  provide  an  occlusion  so  that  sperm  cap.  
● How do the cervical cap differ from the diaphragm? 
cannot  enter  the  cervical  os and ascend into the endometrial 
○ CC: Covers the cervix 
cavity → FT → fertilize 
○ D: fits against the vaginal wall  
● Placed  snugly  against  the cervical opening; set in place in the 
● Requirements​: 
cervical fornices 
○ Normal cervical cytology required 
○ Implication​:  IT  SHOULD  BE  A  PERFECT  FIT  FOR 
○ Pap test THREE MONTHS AFTER  
EACH CLIENT WHO WILL USE THIS METHOD  
○ If  is  doesn’t,  it  will  be  uncomfortable  for  the  client  ■ The RECENT test should be NORMAL 
● Advantages​: 
and  it will cause pressure in the surround structures 
○ Safe and reversible 
like for example: 
○ Good continuation rates 
■ Anteriorly:  urethra,  obstruction  in  urine 
○ Placed longer than the diaphragm 
outflow → UTI  
○ More comfortable 
○ Left in place for 8 hours after last coitus (book) 
 
 
2/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
● Adverse Effects: 
● The  condom  should  be  applied  to  the  erect  penis  before 
○ If left in place for more than 48 hours (>2 days)  
any  contract  with  the  vagina  or  vulva.  The  tip  should 
■ Mucosal ulcerations 
extend  beyond  the  end  of  the  penis  by  about  half an inch 
■ Unpleasant odor 
to  collect  the  ejaculate.  After  ejaculation,  the  penis  must 
■ Infection 
be  removed  from  the  vagina  while  still  somewhat  erect, 
○ AEs also have effects on the cervical tissue.  
and  the  base  of  the  condom  grasped  to  ensure  the 
■ Note: Associated with abnormal cytology 
condom is removed without spillage of the ejaculate. 
3. Male Condoms  ● Water-based lubrication may reduce condom breakage. 
● When  used  by  strongly  motivated  couples,  the  male 
● Latex, polyurethane, or animal tissue (earlier versions) 
condom  is  effective.  The  typical  use  failure  rate  is  around 
● Most  effective  contraceptive  method  to  prevent 
15% 
transmission of STDs​ (latex, polyurethane) 
○ Modern synthetic ones   
○ The  protection  is  not  100%;  not  absolute  in 
4. Female Condoms 
preventing STIs.  
● Ideal for Males with multiple sex partners  ● It does not equal the popularity for the male condom 
● Correct use and careful removal  ● Usage  is  low  compared  to  the  diaphragm  and  cervical  cap. 
● Advantages​:  Why? 
○ Safe, reversible  ○ Expensive 
○ Prevent STD transmission  ○ It  squeaks  during  sex  (HAHA!)  Turns  off  a  lot  of 
○ Highly effective for motivated user  couples 
■ Provides effective contraception  ● It  is  placed  high  in  the  vagina  and  lodged  into  the  fornices 
● How is it used?  providing a barrier for the cervical os. 
○ Steps:  ● There  is  an  excess  material  that  covers  the  perineum  of  the 
■ You  do  not  recycle  for  each  act  of  client 
intercourse  ○ Provides protection for HPV (i.e. genital warts) 
■ While  in  the  process  of  coitus:  do  not  ○ Protection also against STIs 
remove it otherwise it defeats the purpose   
■ Put it as soon as erection occurs 
The  female  condom  consists  of  a  soft,  loose-fitting  polyurethane 
● Do not put it in a flaccid penis 
sheath  with  two  flexible  rings.  One  ring  lies  at  the closed end of the 
● Prior to the sexual act 
sheath  and  serves  as  an  insertion  mechanism  and  internal  anchor 
■ Hold the tip and unroll it. 
for  the  condom  inside  the  vagina.  The  outer ring forms the external 
■ Leave a space to catch the ejaculate 
edge  of  the  device  and  remains  outside  the  vagina  after  insertion, 
■ Appropriate lubrication is needed 
thus  providing  protection  to  the  introitus  and  the  base  of the penis 
● Water  based  ones  are  more 
during intercourse.  
preferable  and  not  the oil based 
ones   
● Oil  based  lubricants  weaken the  ● How is it applied? 
condom material   ○ An  applicator  is  used  to ensure that the blind end is 
■ Upon  withdrawal,  you  have  to  hold  the  firmly  opposed  in  the  upper  vagina  (cervical 
condom  firmly  at  the  base  and  do  not  fornices) 
leave it inside the vaginal canal  ○ Prelubricated  
● It might cause spillage  ○ One-time use only like the male condom 
● This is a type of user failure  ● Advantages​: 
■ After use, proper disposable is practiced.  ○ Fitting not needed (vs. diaphragm and cervical cap) 
● Sanitary way   ○ Can be inserted before starting sexual contact 
● Do  not  dispose/flush  it  in  the  ○ Can  be  left  in  place  for  a  longer  time  after 
toilet (can cause blockage)  ejaculation 
■ You  need  to  be  aware  of  the  expiration  ■ Not beyond 24-48 hours 
date  ○ Additional  protection  for  external  genitalia  (genital 
● NEVER  USE  AN  EXPIRED  herpes) 
CONDOM  ○ Less likely to rupture than male condom 
○ Weakened  and  have  ○ Also reduces risk for HIV and HPV 
microtears 
Advantages of the BARRIER METHOD IN GENERAL 
○ Microtears can provide 
access  for  the  sperm  ● Reduction  of  STD  transmission  especially  if  used  with 
and  infectious  spermicides 
organisms.   ○ Male condom >>> Female Condom 
● If  the  package  is  not  opened,  ● Protection against ​salpingitis​ and c​ ervical neoplasia 
condoms  are  good  up to 5 years   
after the manufacture date.    
● Don't be cheap!    
 
3/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  

NATURAL FAMILY PLANNING METHODS  2. Temperature Method/ Basal Body Temperature (BBT) 
  ● Daily monitoring of temperature 
○ When  the  client  gets  up  from  bed,  get  the 
I.Periodic Abstinence  temperature using standard methods  
● AKA. ​Fertility Awareness methods  ○ Record / Monitor the temperature 
● In this particular technique:   ● Premise:  Abstinence  or  barrier  methods  are  employed  when 
○ You  avoid  coitus  at  the  time  the  ovum  can  be  the woman is potentially fertile.  
fertilized  ● Long insurance 
■ or  during  the  5  days  preceding  ovulation  ○ Coitus  NOT  done  or  a  barrier  is  used  from  onset  of 
or the day of ovulation.  menses  until  3rd  consecutive  day  of  elevated 
○ Highly motivated couples   temperature 
● Because  precisely  identifying  the  timing  of  ovulation  is  ● Low effectiveness so the couple should be highly motivated 
difficult,  several  techniques  of periodic abstinence have been  ● Limitation: The woman should be menstruating REGULARLY.  
utilized.  ○ It  is  difficult  to  monitor  temperatures  if the woman 
● Four methods:  is IRREGULAR.  
○ Calendar/Rhythm  ● No longer used alone.  
○ Temperature  ○ The  trend  is  to  use  the  periodic  abstinence  in 
○ Cervical Mucus  combination 
○ Symptothermal  ■ To  increase  the  overall  efficacy  of  the 
methods.  
1.Calendar Rhythm Method  Taken from PARBS 2020 
● Fertile period based on length of cycles  NFP: Client Instructions for BBT Method 
○ We are hampered by the fact that the luteal phase is  Thermal Shift Rule: 
fixed, the follicular phase is the one that VARIES.   1. Take  temperature  at  about  the  same  time  each 
○ Not  only  between  clients,  but  also  to  the  woman  monitoring  (before  rising)  and  record  temperature  on  a 
also  chart provided by NFP instructor. 
● Determine the longest and shortest interval  2. Use  temperatures  recorded  on  chart  for  first  10  days  of 
○ Monitor or record her menses for 2-3 cycles  menstrual  cycle  to  identify  highest  of  “normal,  low” 
● Shortest cycle subtract 18 and longest cycle subtract 11  temperatures  (i.e.  daily  temperatures  charted  in  typical 
○ Computing  for  the  time  she  is  fertile  (i.e.  she  is  pattern without any unusual conditions) 
ovulating)  3. Disregard  any  temperatures  that  are  abnormally high due 
○ Example:  to fever or other disruptions. 
■ Shortest cycle = 27  4. Draw  a  line  0.05-0.1°C  above  the  highest  of  these  10 
■ Longest cycle = 32  temperatures.  ​This  line  is  called  the  ​cover  line  or 
■ What is the woman’s fertile period?  temperature line. 
Solution​:  27-18  =  9  and  32-11=  20  (21  dapat  diba? 
hehe)  
Note: 18 AND 11 ARE CONSTANTS 
Interpretation​:  The  fertile  period  is  from  days  9  to 
20  (21?)  and  the  couple  should  abstain  or  use 
barriers at this time. 
● Couple abstains during the estimated fertile period 
● Modifications come with a wheel device so that you can move 
it  everyday. (red, blue and green zones) but the formula is still 
applied.  
 

★ The oldest method 

● Principle​: The period of abstinence is determined by 
calculating the length of the individual woman’s previous 
 
menstrual cycle and makes three (3) assumptions: 
○ The human ovum can be fertilized for only about  Taken from the book: 
24 hours after ovulation 
● Other  periodic  abstinence  methods  rely  on  cyclic 
○ Sperm can fertilize for 3 to 5 days ​after​ coitus 
physiologic  changes.  ​Increasing  levels  of  progesterone 
○ Ovulation usually occurs 12 to 16 days ​before 
occurring  after  ovulation  cause  a  detectable  rise  in 
the onset of menses. 
daily basal body temperature. 
● The  woman  therefore  establishes  her  fertile  period  by 
● The  woman  must  abstain  from  intercourse  from  the 
subtracting  ​18  days  from  the  length  of  her  previous 
cessation  of  menses  until  the  third  consecutive  day  of 
shortest  cycle  and  ​11 days from her previous ​longest cycle 
elevated basal temperature, or when she is postovulatory. 
and abstains from coitus during this time. 
 
 

4/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  

3. Cervical Mucus (Billing’s Method)  Periodic Abstinence ADVANTAGES 

● Recognition of changes in the cervical mucus  ★ Safe, reversible, affordable 
○ Everyday you monitor the quality of the mucus  ★ No pharmacologic side effects 
● Abstinence  or  barrier  on  the  first  day  of  copious  slippery  Except  for  the  Kits  mentioned:  cost  effective  majority  of  the  other 
mucus  then  the  ​couple  ​abstains daily until 4 days after the  methods 
last day when the characteristic mucus was observed. 
● “wet” = abstain 
Periodic Abstinence DISADVANTAGES 
● “dry” = safe period  ★ Require highly motivated couple 
● Many things can affect the quality of the mucus  ★ Higher failure and discontinuation rates 
○ Do  not  have  coitus  everyday, dapat every other day  ★ Long period of abstinence 
lang!  ★ Regular cycles (calendar) 
○ You  have  to  allow  the  ejaculate  to  dissipate  and 
take effect on the quality of the cervical mucus.   PART 2: ORAL CONTRACEPTIVES (OCPs) 

● Increasing ​estradiol​ levels increase the production of  ● The most common hormonal contraceptives 
cervical mucus.  ● Most widely used reversible method 
● Intercourse can occur after menses ends until the first day  ○ Because  of  their  effectiveness  and  ease  of 
that copious, slippery mucus is observed to be present  administration 
and again 4 days after the last day when the characteristic  ● There are several formulations:  
mucus was present.  ➔ Estrogen + Progestin (​Combined OCPs​) 

  The  estrogen  component  prevents  a  rise  in  FSH  and  enhances  the 
progestin  component,  which  inhibits  ovulation  and, specifically, LH 
4. Symptothermal Method  surge.  These  dual  actions  lead  to  inhibition  of  follicle  development 
and ovulation.  
● Calendar  +  cervical  mucus  –  to  establish  ​1st  day  of  fertile 
period  ➔ Progestin only (​minipill​) 
● Temperature method​ – to establish ​last​ day 
The  minipill  formulations  consist  of  tablets  containing  low-dose  of 
● The  calendar,  temperature,  and  cervical  mucus  methods  progestin  and  no  estrogen.  They  are  taken  every  day  without  a 
can  be  used  separately  or  in  combination  with  one  steroid-free interval. 
another, or the symptothermal method. 
● Overall typical failure rates are around 24%.   
Additional Notes:  ● Currently: low dose formulations in the market 
○ Lowest EFFECTIVE DOSE 
● Notice  ovulation  symptoms. The "sympto" part of the STM 
requires  that  a  woman  take  note  of  other  physical  ○ To reduce the Adverse effects 
symptoms  of  ovulation,  such  as  increased  cervical  and  ● The  high  doses  of  steroids  in  the original pill formulations 
vaginal  mucus  production,  abdominal  cramping,  breast  caused  minor  side  effects  such  as  nausea,  breast 
sensitivity  and  mood  swings.  Monitoring  mucus  quality  tenderness,  and  weight  gain  that  frequently  led  to 
and quantity is a particularly reliable sign of ovulation.  discontinuation of use. 
● Take  your  temperature  every morning. The "thermal" part  ● Since  that  time,  other  formulations  have  been  developed 
of  the  STM  requires  that  a  woman  take  her  core  body  and  marketed  with  steadily  decreasing  doses  of  both  the 
temperature  each  morning  before  getting  out  of  bed. Use  estrogen and progestin components. 
a  basal thermometer (an especially sensitive thermometer  ● Reduction  in ethinyl estradiol (EE) dose has coincided with 
that  has  a  limited  range)  to  get  a  reading and then record  a  lower  incidence  of  severe adverse cardiovascular effects 
it on a calendar.  and  minor  adverse  symptoms  without  increasing  the 
failure rate. 
Important to Take Note: 
★ All  the  formulations  marketed  contain  less  than  50  µg  of 
Women  with  irregular  cycles  should  not  use  periodic  abstinence 
methods,  over the age of 35, or immediately following a pregnancy​.  EE and 3 mg or less of one of several progestins. 
Women  using  these  methods  should  also  have  control  over  when   
intercourse occurs. 
OCP Formulations 
5.Enzyme Immunoassay Kits 
 
★ Urinary estrogen 
1. Fixed Dose Combination 
★ Pregnanediol glucuronide 
● Expensive  but  not  cumbersome  to  follow  unlike  the  other 
methods of periodic abstinence   ➔ E + P per tablet 
● Looks  like  a  dipstick  or  indicators  to  check  the  level  of  your  Estrogen in the  Ethinyl estradiol, Mestranol 
hormones.   OCP 
● Modern technology  
○ Same  principle  in  using  POCT  blood  glucose  Progestin in the  Levonorgestrel and derivatives 
checking.   OCP  (norgestimate, desogestrel, gestodene) 
 

5/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  

3. Daily progestin/ mini pill 

Norethindrone, norethindrone acetate, 
Norethynodrel, ethynodiol diacetate 
➔ low dose progestin 
 
◆ All in the same colors 
According  to  Dra,  there  are  also  newer 
➔ taken daily at the same time 
ones  available  like  Drosperinone  and 
➔ no steroid free interval 
Cyproterone acetate.  
➔ ideal for ​nursing mothers 
➔ 21 active (for 21 days)  ◆ If for example lactation amenorrhea ends and 
◆ Contain the hormones in equal amounts  she needs further protection 
➔ 7 inert or pill-free days (Withdrawal bleeding/next  ◆ If  they  use  the  COC,  if  you  can  recall  in  the 
menses)  HyperPRL-emia  lecture,  Estrogen  inhibits  milk 
◆ Do not contain any sex steroids  production.  
◆ This withdrawal bleeding usually lasts 3 to 4  Additional Notes: 
days and is ​generally lighter than during menses 
● The most widely used methods combine EE with one of 
in an ovulatory cycle. 
several synthetic progestins. 
◆ Most  products are packaged with inactive spacer 
● The  major  effect  of  the  progestin  component  is  to 
(placebo)  pills  during  the  HFI  to  improve 
inhibit  ovulation,  but  progestins  also  contribute  other 
compliance 
contraceptive  actions  such  as thickening of the cervical 
◆ Some formulations provide an iron supplement 
mucus and thinning of the endometrium. 
in the spacer pills 
● The  major  effects  of  the  estrogen  are  to  maintain  the 
◆ Nice  to  Note:  Other  formulations  provide  a 
endometrium  and  thus  prevent  unscheduled  bleeding 
small  amount  of  EE  (alone  without  progestin) 
as  well  as  to  inhibit  follicular  development  through  a 
during  all  parts  of  the  7-day  HFI  to  reduce 
synergistic effect with the progestin. 
symptoms  associated  with  estrogen  withdrawal 
and  the  resurgence  of  follicle-stimulating   
hormone (FSH). 
★ Women  should  be  advised  that  the  most important pill 
to remember to take is the first one of each cycle. 
★ It  is  particularly  important  that  the  pill-free  interval  is 
not extended more than 7 days. 
★ When  a  woman  misses  two  or  more  pills  in  a pack, she 
should  take  emergency  contraception  and  use  backup   
contraception. 
★ OCs  have  a  1%  failure  rate  with  perfect  use  and  an 
8% failure rate with typical use. 

2. Combination phasic (multiphasic, biphasic, triphasic) 

 
➔ 2-3 different dose of E + P  Legend: Ethinyl estradiol (Top Left), Mestranol (Top Right), Levonorgestrel [and 
◆ Represented in different colors (ex. R,Y,G)  derivatives](Bottom Left), Norethindrone (Bottom Right) 
◆ You also have the steroid free tablets (white) 
OCP Generations 
● Monophasic  products  contain  tablets  with  the  same 
dose  combination  of  an  estrogen  and  progestin  each  ➔ The pill has certainly undergone major changes throughout 
day.  the years. 
● In  multiphasic  formulations,  pills  containing  several  ➔ When  it  first  came  out,  the  pills  contain  high  amounts  of  E 
and  P,  a  lot  of  women  developed  cardiovascular 
different  dose  combinations  come  in  the  same  pack.  A 
complications (like HTN, thromboembolism) 
different tablet color corresponds to each dose 
● Depending  on  the  number  of  different  dose  ◆ Remember: The higher the estrogen, the higher the 
combinations,  these  formulations  are  further  classified  thrombotic adverse effects  
as biphasic, triphasic, or four phasic.  ➔ Reformulation  has  been  done,  the  ceiling  content  of  the 
estrogen  is  50  micrograms  (true  for  2nd  generation  pills daw 
➔ Tablets of same dose given for 5-11 days in the 21-  sabi ni dra, but sa table it is the 1st generation pills)  
medication period  ➔ The 3rd generation has lower doses (~25 micrograms)  
➔ Marketed  to  simulate  the  fluctuations  of  the  hormones  ➔ Key feature: They modified both the dose and the type of 
during  the  menstrual  cycle  in  the  hope  to  have/result  to  estrogen present in the pill 
less adverse effects  ➔ The 4th generation will be utilizing your new progestins  
➔ Not found to have advantage over fixed dose 
◆ Since clinically the said fluctuation simulation  ● Doses with 35 µg or more of estrogen are rarely used 
did not even exhibit.  because of the cardiovascular risks and estrogenic side 
◆ They just add to the cost of the product.  effects. 

6/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  

● The  U.S.  Food  and  Drug  Administration  (FDA)  has  stated  OCP Physiology [Adverse Effects] 
that  the  product  prescribed  should  be  one  that  contains 
the  least  amount  of  estrogen  and  progestin  that  is  Must know!!! 
compatible  with  a  low  failure  rate  and  the  needs  of  the  1. Metabolic Effects  
individual woman. 
Estrogen  ★ Nausea, breast tenderness, fluid 
component  retention 
★ Minor changes in levels of some 
vitamins 
★ Melasma 
★ Mood changes and depression 
★ Irregular bleeding 
★ Headaches (inc. freq.of migraines) 

Progestin  ★ Androgenic effects ​(weight gain, 

component  acne, nervousness) 
★ Adverse mood changes, tiredness 
★ Failure of withdrawal bleeding 
  ★ Irregular bleeding 
★ Headaches 
OCP Physiology [Mechanism of Action] 
Protein  ★ Increase in hepatic globulin 
● Estrogen action 
Metabolism  production (estrogen) ​factors V, VIII, 
○ Inhibition  of midcycle gonadotropin surge [FSH and 
Effects  X, fibrinogen​ → thrombosis 
LH  surge]  and  prevention  of  ovulation  (more 
★ Angiotensinogen​ → BP elevation 
consistent for combined than mini pill) 
★ Sex hormone binding globulin (SHBG) 
○ Progesterone  can  also  have  gonadotropin 
reduced by androgens, including 
inhibition (to a less extent) 
androgenic progestins 
● Progestin action 
○ thick, viscid, scanty cervical mucus  Carbohydrate  ★ Related to dose, potency, structure of 
○ alters endometrium  Metabolism  progestin 
■ Thinning of the endometrium 
Effects  ★ Higher dose potencies and dose → 
● Reduces the likelihood of 
greater impairment of glucose 
implantation  metabolism 
○ In the oviducts/Fallopian tubes  ★ Gonanes​ (LNG and derivatives) ​more 
■ Reduce the ciliary action  
than your ​Estranes​ (Norethindrone 
● Interfere with the gamete 
and derivatives) 
transport 
Weight gain represents a common complaint of 
■ In older books, if the OCP fails this might 
women using hormonal contraception.* 
result to Ectopic Pregnancy  

● Contraceptive  steroids  prevent  ovulation  mainly  by  Lipid Metabolism Effects*** 

interfering  with  release  of  gonadotropin-releasing  Note: Newer derivatives of LNG – ​less androgenic, more lipid 
hormone (GnRH) from the hypothalamus.   friendly (they resemble estrogen) 
○ Most  studies  also  support  that  contraceptive 
steroids  directly  suppress  the  pituitary  in  Estrogen  ➔ Increase: HDL, total cholesterol, TGs 
addition.  ➔ Decrease: LDL 
● With  all  OCs,  neither  gonadotropin  production  nor 
ovarian steroidogenesis is completely abolished.   Progestin  ➔ Increase: LDL 
○ Levels  of  endogenous  E2  in the peripheral blood  ➔ Decrease: HDL, total cholesterol, TGs 
during  ingestion  of  combination  OCs  are  similar 
to  those  found  in  the  early  follicular  phase  of  a  Coagulation  Estrogen increase: some coagulation factors 
physiologic cycle.  Parameter  (e.g. fibrinogen) → ​enhances thrombosis  
● The  balance  between  estrogen  and  progestin  influences  Effects  *This is dose dependent 
the bleeding profile of a combination OC. 
○ The  bleeding  that  users  of  combined  OCs  2. Cardiovascular Effects 
experience  during  the  hormone-free  interval  is 
Venous  The  risk  is  greater  for  higher  doses  (>50  µg)  of 
called  ​withdrawal  bleeding​,  as  it  occurs  upon 
thrombo-  estrogen.  That  is  why  the  ceiling  dose  is  50 
cessation of the progestin component of the pill 
○ Bleeding  that  occurs  during  the  time  that  active  Embolism (VT)  micrograms* 
pills  are  ingested  is  called  ​breakthrough 
Myocardial  There is no evidence of increased risk of MI from 
bleeding. 
Infarction (MI)  atherosclerosis 
 
7/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
○ Manage and normalize first the problem in BP 
Stroke  It has conflicting results ; no increased risk for 
● Existing breast and endometrial cancer 
past users compared to never users 
● Undiagnosed uterine bleeding [Check AUB trans!]  
● Elevated triglycerides 
Take  Note:  A  woman’s  baseline  risk  of  venous 
● Pregnancy 
thromboembolism  (VTE)  increases  by  three  times  if  she  ingests 
○ Establish first and make sure that the client is not 
estrogen-containing  oral  contraception.  ​Screening  for 
pregnant 
coagulation  deficiencies  should  only  be  performed  before  starting 
● Functional heart disease 
OC use : ​if the woman has a family history of thrombotic events. 
● Active liver disease 
● Obesity is a modest risk factor for VTE 
○ Compromise the metabolism of sex steroids 
● Extreme  obesity (e.g., a body mass index [BMI] >40) should 
be  considered  a  relative  contraindication  to  use  of  a  OCPs: Relative Contraindications 
combined hormonal method.  
Case to case basis, weigh the pros and cons* Make sure to inform the 
● Use  of OCs by women older than age 35 who also smoke is 
contraindicated due to the risk of myocardial infarction.  patient here.  
● Heavy smokers (<35 years old) 
3. Reproductive Effects  ● Migraines 
○ Not all women on OCPs will aggravate migraine 
➔ No permanent infertility!   ○ It varies from woman to woman 
➔ HPO suppression is ​temporary​ and ​reversible  ○ Ask the patient if she is suffering as such 
◆ After  discontinuation  of  low-dose  OCs,  the  ● Undiagnosed cause of amenorrhea 
suppressive  effect  on  the  ○ Maybe the patient is pregnant 
hypothalamic-pituitary-ovarian  axis  disappears  ● Depression 
quickly  ○ Check first the degree of depression 
➔ Length  of  delay  of  return  to  fertility  related  to  estrogen  ○ Make sure that the condition is managed  
dose and user age not duration of use  ● Prolactin-secreting macroadenomas 
➔ Pregnancy  immediately  after  discontinuation  not  ○ Sex steroids could worsen the progression of these 
associated with higher abortion or anomaly rates.   macroadenomas 

ADVANTAGES OF OCPs in General 

4. Neoplastic Effects (the controversial of the 4) 
● Highly effective form of contraception 
Breast Cancer*  no significantly higher risk compared to never  ● Convenient 
users  ● Readily available 
○ You can choose what you can afford 
Cervical Cancer  uncertain​, conflicting evidences  ○ 4th generation pills are more expensive  
This is considered to be a gray area in research.  ● Affordable 
● Easy administration 
Liver Adenoma  high dose mestranol formulations  ● Many non-contraceptive health benefits (check the next 
Since  this  is  not  available  in  the  market,  the  section) 
newer ones have low amounts of this. The effect 
is considered to be now insignificant.  Non Contraceptive Health Benefits  
 
Additional Notes: 
● Studies  have  consistently  demonstrated  a  strong  Protective  ★ Endometrial cancer 
protective effect between OCs and ​Endometrial cancer​.  against the  ★ Colorectal cancer 
● Numerous  epidemiologic  studies  have  consistently  following  ★ Ovarian cancer 
demonstrated  that  OCs  reduce  the  risk  of  developing  cancer:  Mnemonic: E.C.O. All the 3 are related (BRCA 
Ovarian cancer.  gene) And from I can recall in the AUB lecture, 
iisa kasi sila daw ng anlage kaya ganun.  
○ OCs  ​reduce  the  risk  of  the  ​four  main  histologic 
types of epithelial ovarian cancer​:  
Antiestrogenic  ● Reduction  of  menstrual  blood  loss 
■ serous,  mucinous,  endometrioid, 
effects of  and  less  risk  for  iron  deficiency 
and clear-cell 
progestin  anemia 
■ the  risk  of  both  invasive  ovarian 
(Especially the  ● Less  incidence  of  menorrhagia, 
cancers  and  tumors  of  low  malignant 
newer ones)  irregular  menses  and  intermenstrual 
potential (borderline tumors). 
bleeding  (IMB)  as  long  there  is  no 
  organic cause 
● Less  likely  to  develop  endometrial 
OCPs: Absolute Contraindications  adenocarcinoma 
● History of vascular disease  ● Reduction  of  incidence  of  benign 
● Systemic diseases affecting vascular system  breast  diseases  (like  fibroadenoma  or 
● Smokers older than 35 (>35 y/o)   fibrocystic dse. )  
○ Synergistic effect of nicotine and estrogen 
● Uncontrolled hypertension  Inhibition of  ● Less  dysmenorrhea  and  premenstrual 

8/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
○ Delaying  the  start  of  a  pill  pack  can  lead  to 
Ovulation  tension  
unintended pregnancies 
○ Lessen  the  complaints 
★ Medical comorbidities (DM, HPN, heart diseases) 
associated  during 
Notes regarding Follow up:   
menstruation 
● Lab test not necessary for Healthy women 
○ Premenstrual 
○ No need to request for battery exams 
Symptomatologies  (PMS) 
● Non-directed history and BP after 3 months 
relief   
○ Be careful in asking questions for symptoms  
● Protection against development of 
○ Avoid Leading the patient to the concerns  
functional ovarian cysts (Follicular, CL 
○ Let the patient tell you if may nararamdaman siya 
and TL cysts) 
● Annual visits:  
● Reduction  in size of functional ovarian 
○ Done 3 months after she has finished the regimen 
cyst 
○ Monitor the ff parameters:  
● Protection vs ovarian cancer 
■ BP, Weight, Complete PE, Cytology (Pap 
Smear)  
Other Benefits  ● Risk reduction rheumatoid arthritis 
(Mechanism  ● Protection against PID  LONG-ACTING HORMONAL CONTRACEPTION (LAHC) 
remains  ○ Due to the scanty discharge  
unknown)  ● Reduction in incidence of ectopic  ● These go beyond the contraceptive effects of the OCPs 
● One  advantage  of  which  is  the  less  frequency  of 
pregnancy (EP) 
○ This is true for the COCs, not  administration  
for the POPs (Progestin-Only  ● There  are  four  types,  although  technically  IUD  is  not 
Pill)  hormonal but it is long-acting.  
● Reduction of bone loss  ○ If IUD: inert 
○ Hormonal therapy for  ○ If IUS: it contains hormones 
Perimenopausal women  ○ Implants: subdermally; do a minor procedure 
○ Estrogen in the pill provides  ○ Vaginal ring 
protection against  ● These are expensive  
osteoporosis  Contraceptive Patch 
Important Points in Prescribing Oral Contraceptives:  ➔ Brand Name: ​Ortho Evra 
★ Adolescent  ■ Transdermal delivery  
○ A  pubertal  girl  who  has  demonstrated  maturity  of  ■ Contains  about  75  micrograms  of 
the  hypothalamic-  pituitary-ovarian  axis  with  ethinyl  estradiol  and  6  mg  of 
presumably  ovulatory  menstrual  cycles  can  begin  norelgestromin 
OCs without concern  ■ One  patch  is  applied  to  the  skin  each 
○ Baka  lang  daw  di  tumangkad or not achieve the full  week  for  3  consecutive  weeks  and  ​no 
height  potential  (estrogen  affects  the  epiphyseal  patch  for  the  following  week  of  a  4-week 
growth plates)   cycle to allow withdrawal bleeding. 
★ After pregnancy  ■ The  patch  may  be  applied  to  one  of  four 
○ For  women  who  deliver  after  28  weeks  and  are not  anatomic sites:  
nursing,  t​he  combination  pills should be initiated  ● buttocks 
no  sooner  than  6  weeks  after  delivery  as  the  ● upper outer arm 
increased  risk  of  postpartum  thromboembolism  ● lower abdomen 
may  be  further  enhanced  by  the  hypercoagulable  ● upper  torso  excluding  the 
effects of combination OCs.   breasts 
○ Progestin-only  methods  can  be  initiated  ■ The  MOA  is  similar  to  the  OCPs  (​in  the 
immediately.  book  actually  this  is  discussed  next  to 
★ Nursing/breastfeeding mothers  OCs) 
○ Estrogen  inhibits  the  action  of  prolactin  in  breast  ● The  inhibition  of  gonadotropin 
tissue  receptors;  therefore,  the  use  of  combination  release  
OCs  (those containing both estrogen and progestin)  ● The prevention of ovulation. 
diminishes  the  amount  of  milk  produced  by  OC 
users who breast-feed their babies.  Contraceptive Vaginal Ring 
○ The  diminution  of  milk  production  is  directly 
➔ Brand Name: ​NuvaRing 
related  to  the  amount  of  estrogen  in  the 
■ The  steroids  are  delivered  to  the  vaginal 
contraceptive formulation 
mucosa directly and into the circulation 
○ The  major  concern  is  that  combined  OCs will lower 
■ A flexible ring-shaped device containing 
the success of initiation of lactation 
2.7  mg  of  ethinyl  estradiol  and  11.7  mg 
★ Cycling Women  of etonogestrel 
○ Woman may find it convenient to start a pill pack on 
■ This  is  placed  in  the  vagina  for  21  days 
a particular day of the week 
and  then  ​removed  for  up  to  7  days  to 
○ Sunday  starts  have  been  a  popular  allow withdrawal bleeding 
recommendation 
9/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
● After  this  ring-free  interval  the  ○ Ovarian cysts 
woman inserts a new  ○ Dysmenorrhea 
● ring  regardless  of  whether  ○ Endometriosis 
withdrawal  bleeding  has  ○ Epileptic seizures (mechanism unknown) 
occurred.  ○ Vaginal candidiasis 
● Because  the  steroids  act  Disadvantages and Adverse Effects 
systemically,  ​the  ring  comes  in  *most common 
only  one  size  and  does  not  ○ Unscheduled or irregular bleeding* 
have  to  be  fitted or placed in a  ■ Reassure  the  patient  and  send  home 
certain location.  ganern yung sagot pag ganun 
○ Compared  to  your  ■ This is just the thinning effect of progestin 
diaphragm  and  ○ Delayed resumption of ovulation*  
cervical caps  ■ Not  like  in  the  OCP,  na  babalik  agad 
● MOA: (​ bread and butter na ito sa  diba, ito hindi.  
Gyne  guys  don’t  forget  ■ One  journal  said  11-12  months  after  the 
hanggang  sa  mag  PLE  tayo  last dose 
soon!)   ■ If  they  are  asking  for  next  pregnancy, 
○ The  inhibition  of  explain this to your client. 
gonadotropins  ○ Weight gain 
○ The  prevention  of  ■ About  one  fourth  of  women  using  DMPA 
ovulation.  gain  weight,  usually  in  the  first  6  months 
● Ring  expulsion  is  uncommon,  of use 
and  both  partners  typically  ■ unclear 
report  high  acceptability  with  ○ Depression and mood changes  
use.  ■ no clinical trials for evidence 
Injectable Suspensions  ○ Headache 
■ most  frequent  medical  event  reported  by 
● It has 3 Formulations:  DMPA  users  and  a  common  reason  for 
1. DMPA (Progestin-only)  discontinuation of its use 
2. Norethindrone enanthate (Progestin-only)  ■ not enough studies 
3. Estrogen + progestin formulations  ○ Metabolic effects 
● These  are  very  convenient  if  the  user  tends  to  forget  to  take  ■ insignificant  effects  on  lipid,  glucose  and 
pills everyday.   protein metabolism 
● Affordable type of hormonal contraception  ● lowers  HDL  but  DMPA  not 
demonstrated  to  accelerate 
DMPA (depo-medroxyprogesterone acetate)  
atherosclerosis. 
➔ Brand name: ​Depo-Provera  ○ Bone  loss  suggested  in  some  studies  but  is 
● Very effective reversible method   reversible 
● Given  in  a  dose  of  150  mg  intramuscularly  (IM)  or  104  mg  ■ Because  DMPA  suppresses  production 
subcutaneously (SC) every 3 months  of  estradiol,  bone  remodeling  is 
● It  is  the  only  injectable  contraceptive  available  in  the  United  increased  and  may  resemble 
States  menopause. 
● Given within the first 5 days of the cycle  ■ Calcium  supplementation  may  be 
● MOA: ​Remember these THREE  warranted 
○ Inhibition  of  ovulation  (Progestin  can  have  diba?  ■ Measurement  of  bone  mineral  density 
pero not to a great extent tandaan niyo ito!)   (BMD)  during  DMPA  use  is  unnecessary 
■ By  suppressing  levels  of  FSH  and  LH  and  because  bone  density  increases  after 
eliminating the LH surge  stopping DMPA 
○ Thickening of cervical mucus   Note:  Bisphosphonate  therapy should not 
■ Inhibiting  sperm  from  reaching  the  be used in DMPA users with low BMD. 
oviduct  ○ Neoplastic effect 
○ Altering the endometrium  ■ Does  not  affect  incidence  of  breast, 
■ Which causes atrophy of the uterine lining  cervical, ovarian cancers 
● When  used  correctly  and  consistently,  the  chance  of 
pregnancy is 0.2%.   Subdermal Implants 
● Typical failure rates are around 6%.   ● Another  form  of  steroid  delivery  but  a  minor  surgical 
● These effectiveness rates apply to women of all body weights.  procedure to place the implant (OPD setting) 
Benefits of DMPA injectable:   ● Deliver progestins for as long as 7 years.  
★ Definite risk reduction  ● Removal is important, placing a new one into the other arm. 
○ PID and salpingitis  ● The  user  should  palpate  signifying  that  the  implant  is  in 
○ Endometrial cancer  place. 
○ Iron deficiency anemia  ● MOA: same as injectables 
○ Sickle cell problems  ● Brand Name: ​Nexplanon (68 mg of etonogestrel)  
10/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
 
★ Impedance of sperm 
DMPA and Implant: Advantages: 
transport and viability 
● No daily intake of pills 
in the cervical mucus 
○ For those busy clients 
(Copper) 
○ To improve compliance  
● Infrequent administration 
IUD INSERTION: 
● Maybe  appropriate  for  those  with  contraindications  to 
This is a very common question asked by clients* 
estrogen 
● Any day of the cycle provided the receiver is NOT 
○ Nursing/Breastfeeding clients  
PREGNANT 
○ Clients  who  are  afraid  of the effects of estrogen can 
● No ongoing cervical/vaginal infections 
benefit from using implants 
Implants: Disadvantages and Adverse Effects  The IUD can be safely inserted in any of the following 
● Unscheduled or irregular uterine bleeding  scenarios: 
● Need  for  minor  surgical  procedure  to  insert  and  remove  1. on any day of the cycle provided the woman is not 
device  pregnant 
● Operative site-potential site for infection (uncommon)  2. immediately postabortion 
3. Immediately postpartum following either vaginal or 
Intrauterine Device and Intrauterine System  cesarean section delivery. 
  ➔ Immediate postpartum insertion carries a 
higher risk of IUD expulsion, particularly in 
● A  safe  and  highly  effective  method  of  birth  control  with 
the case of an LNG-IUS following vaginal 
similar rates of failure for typical or perfect use  delivery 
● The ​IUD is the most ​commonly used ​reversible method of 
contraception worldwide.   

  ADVANTAGES OF IUD:  POTENTIAL ADVERSE EFFECTS: 

Types of IUDs  ● Highly effective  ● Uterine bleeding 
● Long term (12 years)  (Copper T380A) 
  ● No associated  ● Perforation during 
Copper T 380A IUD (Paragard)  LNG-IUS (Mirena)  systemic metabolic  insertion 
effects  ● Infection 
● Single act of  ● Complication relating 
motivation  to pregnancy with 
● Highest continuation  IUD-in-utero 
rate of all reversible 
Pregnancy w/ IUD-in-Utero: 
methods 
-​Congenital anomalies 
● No permanent effects 
    ● no increased risk 
on fertility 
-Spontaneous abortion 
***For LNG IUS – reduces 
● the  only  ● The LNG-IUS has a high  -Septic abortion 
Menstrual Blood Loss (thinning 
copper-bearing  IUD  level of effectiveness  -Ectopic Pregnancy 
of the endometrium) vs Copper 
currently  marketed  in  for at least: ​5 years  ● IUDs  effectively 
T 380A 
the United States,  ● Reduces  menstrual  reduce  all 
CONTRAINDICATIONS OF IUD: 
● A new copper IUD  blood  loss  and  has  pregnancies 
● Pregnancy or 
(Veracept) is  been  used  including ectopic. 
suspected pregnancy 
undergoing clinical  therapeutically  to treat  ● Ectopic pregnancy 
● Acute PID 
trials.  excessive  uterine  is reduced by 90% 
● Postpartum 
● Approved use: ​10  bleeding  (If  you  can  compared to those 
endometritis  or 
years  recall,  first  line  siya  for  w/o contraception. 
infected  abortion  in 
● Maintains its  CHRONIC AUB)   ● But if pregnancy 
the last 3 months 
effectiveness for at  ● A  slightly  smaller  body  does occur with the 
● Known or suspected 
least: ​12 years   than  the  Mirena  has  IUD in place, the risk 
uterine or cervical CA 
been  approved  for  up  of it being ectopic 
● Genital bleeding of 
to  ​3  years  of  use  increases 3-fold. 
unknown origin 
(Skyla)  -Prematurity 
● Untreated acute 
Mnemonic: P.E.C.S.S. 
cervicitis 
MOA:   MOA:  ● Previously inserted 
★ Spermicide​ (local  ★ Spermicide  IUD that does not 
sterile inflammation)  ★ Progestin effects 
been removed 
○ It take the  ○ Since it   
advantage  contains 
of being a  levonor-   
foreign body  gestrel* 
-Last part na guys! Kapit lang. God bless you with patience and perseverance!  

11/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  

PERMANENT CONTRACEPTION: STERILIZATION  in  the  office  with  Difficult  and 

only  local  meticulous  reversal 
● Structures affected: 
anesthesia.  or  reanastomosis 
○ Fallopian tubes: females 
  procedures  with 
○ Vas deferens: males 
-It  does  not  involve  success  rate  ​only 
● Reversals/Reanastomosis are difficult 
entry  into  the  50% 
○ The  success  rates  are  said  to  be  variable  (at  most 
peritoneal cavity   
~50% according to Dra.) 
  Sterility is not 
● Pregnancy rates: extent of damage, surgeon’s expertise  -Efficacy is easily  immediate, because 
● Male and female sterilization are safe and highly effective  verified  there are still viable 
methods of contraception.   sperm in the DISTAL 
● In  contrast  to  the  other  methods  of  contraception,  which  PORTION  
are  reversible  or  temporary,  sterilization  should  be   
considered permanent. 
○ If  women  who  have  tubal  sterilization  wish  to 
conceive,  in  vitro  fertilization  is  now  being 
performed  more  frequently  than  tubal 
reconstructive surgery. 
● Legal  in  all  50 states in the US. (even in the Philippines it is 
done) 
Note:  When  a  woman  younger  than  age  30  requests  sterilization, 
 
there is up to a 20% risk of regret following sterilization 
[Scan the QR code to read more about Vasectomy, this is discussed very shortly in the book] 
   

Male Sterilization  Female Sterilization 

  ➔ Done  after  several  hours  after  delivery before the patient can 

go home the next day (done also in government hospital) 
Also known as ​Vasectomy  ➔ If CS: Done prior to closure 
● Short outpatient procedure  ➔ If NSD: Done with a small umbilical incision  
● Local anesthesia   
● Sterility after 14-20 ejaculations 
○ In the book it is 13 to 20 ejaculations   ● This is the most prevalent method of contraception used 
by U.S. women over the age of 30 
○ This must occur after the operation before the 
ejaculate will be sterile.  ● Female sterilization is highly effective, in the same tier of 
● 2 aspermic ejaculates required  contraception effectiveness as LARC methods. 
○ The absence of sperm is confirmed with a  ● Risk factors for failure included age and method of 
semen sample.  sterilization;  
○ Until that time, another method of birth control  ○ The younger the woman, the higher the risk of 
must be used.  failure. 
Nice  to  note:  Postpartum  partial  salpingectomy  carried  the  lowest 
★ It is a safe and highly effective outpatient procedure  10-year  cumulative  risk  of  failure  and  Hulka  clips  (not  available 
that takes about 20 minutes and requires only local  anymore)  carried  the  highest  risk.  Filshie  clips  also  show  a  10-year 
anesthesia.  cumulative failure.  
● The vas deferens is isolated and cut. The ends of the 
vas are closed, either by ligation or by fulguration, and   
then replaced in the scrotal sac.  Bilateral Tubal Ligation (BTL) 
○ This occlusion of the vas prohibits sperm  ● More complicated 
from passing into the ejaculate.  ● Transperitoneal incision 
○ The ejaculate is therefore sperm free, but  ● Often under general anesthesia IV, but can be also under 
otherwise unchanged.  local anesthesia 
  ● Postpartum or interval 
● Mini Laparotomy or laparoscopy 
Complications  Advantages  Disadvantages  ● Most effective and least destructive type of BTL 
○ preferred for young women (​Modified Pomeroy 
Hematomas  -The  procedure  is  Reversal  requests  and laparoscopic band technique​) [picture on 
  low  cost.  ​It  is  the  range  from  5%  to  the right below] 
Sperm granulomas  most  cost-effective  7%  among men who  ● Failure  rates  increase  with  duration  of  time  from 
  of  all  contraceptive  have  had  a  procedure​ (esp. bipolar coagulation and spring clips) 
Spontaneous  methods.  vasectomy.   ● Fimbriectomy can also be done 
reanastomosis      ○ Preventive of ovarian cancer 
-It  can be performed    ○ Protect  the  ovaries  from  substances  coming out 
of the tube (i.e.oncogenic) 

12/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  
Note:  Multiple  studies  indicate  a  reduced  risk  of  ovarian  cancer 
TRANSABDOMINAL APPROACH  following  tubal  ligation.  Current investigations are under way to assess 
an  improvement  in  risk  reduction  when  using  bilateral  salpingectomy 
➔ Tubal occlusion can occur at the time of cesarean  rather than simple tubal ligation. 
section, immediately postpartum through an: 
KEY POINTS/GYNE PEARLS 
◆ infraumbilical minilaparotomy while the 
uterus is still enlarged.  ● Failure  rates  in  the  first  year  of  contraceptive use are highest 
◆ during an interval minilaparotomy  for  coitus-related  methods  (e.g.,  withdrawal,  periodic 
➔ Ligation  and  resection  of  a  portion  of  both  fallopian  abstinence,  condoms,  barrier  methods)  followed  by 
tubes  using  a  technique  such  as  the modified Pomeroy  combined  contraceptives  (pill,  patch,  ring)  and the progestin 
method is common  injection.  The IUD, implants, and sterilization have typical use 
➔ These  methods  involve  general  or  regional  anesthesia,  failure rates of less than 1%, similar to that of sterilization. 
though local anesthesia is possible  ● The  copper  IUD  can  increase  bleeding  with menses, whereas 
the  LNG-IUS  is  likely  to  decrease  bleeding  with  menses  or 
LAPAROSCOPIC APPROACH  lead to amenorrhea. The primary mechanism of action for the 
LNG-IUS is thickening of the cervical mucus. 
➔ General anesthesia is usually used for laparoscopic  ● The  contraceptive  implant  has  an  effectiveness  that  is  equal 
sterilization  to  or  superior  to  that  of  sterilization  and  IUDs.  It  inhibits 
➔ This method was abandoned due to an increased risk of  ovulation and may cause irregular bleeding patterns. 
surgical complications.  ● The  DMPA injection completely inhibits ovulation and is likely 
➔ The  most  common  techniques  used  today  include  to  cause  amenorrhea.  Return to fertility after cessation of use 
bipolar  cautery,  the  Filshie  clip,  and  the  Silastic  band  can  be  delayed,  and  some  DMPA  users  may  experience 
(Falope ring).  weight gain. 
● Combined  hormonal  contraceptives  increase  a  woman’s  risk 
TRANSCERVICAL APPROACH  of  VTE  by  about  threefold  to  about  1/1000  per  year.  Women 
with  multiple  risk  factors  for  VTE  or  cardiovascular  disease 
➔ Sterilization  using  the  Essure  device  involves  the  (e.g.,  obesity,  age  >35,  smoking,  a  personal  or  family  history 
introduction  of  a  microinsert  device  transcervically  of  clotting  disorder)  should  use  effective  birth  control 
through a hysteroscope  methods without estrogen. 
➔ The device is placed in the proximal portion of the 
fallopian tube.  TIER 1 METHODS​: ​HIGHLY EFFECTIVE  
➔ Over time, the device causes tissue ingrowth and  (FEWER THAN 1 PREGNANCY PER 100 WOMEN IN 1 YEAR): 
permanent tubal occlusion  INTRAUTERINE DEVICES (IUDs), IMPLANTS, MALE AND  
➔ A  hysterosalpingogram  is  performed  3  months  after  FEMALE STERILIZATION 
insertion to document tubal occlusion 
➔ Anesthesia  options  include  local  anesthesia,  TIER 2 METHODS​:​ VERY EFFECTIVE  
intravenous sedation or general anesthesia.  (6 TO 12 PREGNANCIES PER 100 WOMEN IN 1 YEAR): 
◆ The  use  of  local  anesthesia  at  the  time  of  INJECTABLES, PILLS, PATCH, RING 
laparoscopic  tubal  ligation  reduced 
TIER 3 METHODS​:​ EFFECTIVE  
postoperative  pain  for  up  to  8  hours  after 
(18 OR MORE PREGNANCIES PER 100 WOMEN IN 1 YEAR):  
surgery.  
BARRIER METHODS, LACTATIONAL 
  AMENORRHEA, PERIODIC ABSTINENCE, 
COITUS-RELATED METHODS 
Complications 
★ Bleeding  Additional Notes: 
★ Anesthetic Complications  ● Emergency contraception (EC)​ ​allows women to prevent 
★ Bowel Injury (laparoscopic electrocoagulation)  pregnancy after an act of unprotected intercourse. 
★ Uterine perforation and Device expulsion (micro  ○ Commonly mis described as the morning-after 
inserts)  pill, EC can actually be used up to 120 hours after 
★ Infection  intercourse, depending on the method 
Mnemonic: B.A.B.U.I oink*   ● Induced abortion​ is one of the most common gynecologic 
operations performed in the United States.  
● The state may not interfere with the practice of abortion in 
the first trimester. In the second trimester, individual 
states may regulate abortion services in the interest of 
preserving 
the health of the woman. 
★ Safe and legal abortion services are a cornerstone of 
maternal health care.  
  ★ Illegal abortion is one of the leading causes of maternal 
​[Scan the QR code for the different techniques of BTL, one of which is the Pomeroy Method]   death 
★ Methods of Abortion: Curettage, ​Laminaria japonica​, 

13/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches  
  

Mifepristone(RU-486), 

 
Figure 13.1 page 239 of WHO’s tiered approach contraception counseling 
tool comparing typical effectiveness of contraceptive methods​. 
 
 
 
 
 
 
 
 

14/14 Sources: PPT 2021 + Compre Gyne 7th Ed. + Gyne Manual + Transes from Previous Batches