Family Planning

Contraception
Who are Contraceptive Users?

• 70% of women ages 15 to 44 at risk of unplanned pregnancy

• women are sexually active
• capable of becoming pregnant
• not currently pregnant or postpartum
• are not trying for pregnancy
Contraceptive Effectiveness

Typical use effectiveness

pregnancy rate given actual use, including occasional

inconsistent or incorrect use

Perfect use effectiveness

pregnancy rate given correct and consistent use of a

method with every act of intercourse
TIER 1 METHODS

• HIGHLY EFFECTIVE
• FEWER THAN 1 PREGNANCY PER 100 WOMEN IN 1 YEAR
• Long-active reversible contraception (LARC)
• INTRAUTERINE DEVICES (IUDs)
• IMPLANTS
• MALE AND FEMALE STERILIZATION
 Long-active reversible contraception
(ARC)
• require only one act of motivation
• eliminates user error once placement has occurred
• highly effective and immediately reversible with a rapid return to
fertility after removal
• few medical contraindications
• do not require frequent visits for resupply or incur costs after
placement (though upfront costs can be high)
• high continuation rates and user satisfaction
 Long-active reversible
contraception (LARC): IUD
• Intrauterine device
• failure rates with the are less than 1%
• copperT 380A IUD
• levonorgestrel-rejeasing IUD
Long-active reversible
contraception (LARC): IUD
Copper T IUD
require periodic replacement 10 years and maintains its effectiveness
for at least 12 years
Long-active reversible
contraception (LARC): IUD
• 20 gg of levonorgestrel(LNG)
• released into the endometrial cavity each day
• high level of effectiveness for 5 years
• also reduces menstrual blood loss
• used to treat excessive uterine bleeding
IUD Mechanism of Action

induce a local inflammatory reaction of the endometrium

creating an environment that is hostile to sperm so that
fertilization does not occur
Mechanism of Action:
uuso
• thicken cervical mucus, impedes sperm penetration and access
to the upper genital track
• decreases tubal motility
• produces a thin, inactive endometrium
• low levels of circulating steroid sometimes inhibit ovulation
When to insert an IUD?

any day of the cycle provided

the woman is not pregnant

immediately postabortion

immediately postpartum
following either vaginal or
cesarean section delivery

IUD expulsion rate 24%

Adverse Effect of IUD

• Uterine Bleeding
• Perforation
• Complication related to pregnancy
• Infection in a non pregnant user
LNG-IUD: Side Effects

60% reduction of MBL as early as 3 months after insertion

after 24 months of use

50% amenorrhea

25% oligomenorrhea

prevention and the treatment of iron de ciency anemia.

Adverse Effect of IUD

• Copper T: uterine bleeding

• heavy or prolonged menses or intermenstrual bleeding
• produced by an increased rate of prostaglandin release in the presence
of the intrauterine foreign body
• stimulation of uterine contractions by prostaglandins may prolong
menses
Copper T: uterine bleeding

reassurance
• bleeding usually diminishes with time, as the uterus adjusts to the
presence of the foreign body
• give supplemental oral iron
Adverse Effect of IUD:
Perforation
1 in 1000 insertions
perforation at the funds
always begins at the time of insertion
best prevented by straightening the uterine axis with a
tenaculum and then measuring the cavity with a uterine sound
before IUD insertion
Adverse Effect of IUD:
Perforation
• On follow up post insertion..
• suspect a perforation if the user cannot feel the threads and did
not observe that the device was expelled OR
• sometimes the IUD is still in its correct position in the uterine
cavity, but the threads have been withdrawn into the cavity as
the position of the IUD has changed
• do pelvic examination
• do pregnancy test
Adverse Effect of IUD:
Perforation
• On follow up post insertion...
• transvaginal ultrasound - > to locate the device
• If not visualized, a radiograph of abdominal cavity visualize the entire
pelvis and abdomen
• IUDs found to be outside the uterus usually can be removed by
means of laparoscopy
Adverse Effect of IUD:
Complications Related to Pregnancy
• extrauterine location is more likely
• do pelvic ultrasound must be carried out to locate the pregnancy
• if intrauterine pregnancy, the device should be removed
regardless of whether the pregnancy is desired or undesired
Adverse Effect of IUD:
Complications Related to Pregnancy
• as the uterus grows with the pregnancy, the threads will
eventually be drawn inside the cervix and become inaccessible
(+) pregnancy, the IUD is not subsequently removed, the
incidence of spontaneous abortion is approximately three times
greater
 Adverse Effect of IUD:
Infection in the Nonpregnant IUD User

• IUD may be placed without cervical screening for infection

• clinical suspicion of infectious endocervicitis, or the patient has
two out of three of the following:
• (1) purulent vaginal discharge
• (2) adnexal tenderness
• (3) cervical motion tenderness
• perform testing for gonorrhea and chlamydia and delay IUD
insertion
 Adverse Effect of IUD:
Infection in the Nonpregnant IUD User

with IUD but (+) gonorrhea or chlamydia

screening tests .2
with IUD,fRve PID CDC regiment
until symptom free
• If the or if there is evidence of tubo•ovarian
abscess, the device should be; d
• give alternative method of contraception
Contraindications

• pregnancy or suspicion of pregnancy

• acute PID
• postpartum endometritis or infected abortion
• known or suspected uterine or cervical malignancy
• genital bleeding of unknown origin
• previously inserted IUD that has not been removed
• Few data: Wilson disease or an allergy to copper are true
contraindications for insertion of copper-bearing IUDs
Overall IUD Safety

reduction in risk of developing these

neoplasms(cervical and ovarian)

Laurelli, 2011: use of LNG-IUS as a fertility-sparing

treatment of early stage endometrial cancer

useful method of contraceptionfor women who have

completed their families and have contraindications to
sterilization
Subdermal Implant

•o consist of one or more thio

rods containing a„progestin
hormone
• insertion as outpatient
• skin infiltrated with local
anaesthesia 0.
• inserted superficially into the of impurit
subcutaneous tissue of the With control
implÄ1
upper arm using a tracer
• insertion site is closed with
adhesive, no need to suture
TIER 2 METHODS:

VERY EFFECTIVE
6 TO 12 PREGNANCIES PER 100 WOMEN IN 1 YEAR

INJECTABLES

PILLS
FATCH

Vaginal RING
Medroxyprogesterone acetate

• Depo-Provera, or depo-medroxyprogesterone acetate (DMPA)

• dose of 150 mg intramuscularly every 3 months
 Medroxyprogesterone acetate
(MPA)
• mechanisms of action:
• inhibition of ovulation by suppressing levels of FSH and LH and
eliminating the LH surge
• thickening of cervical mucus inhibiting sperm from reaching the oviduct
• altering the endometrium -> atrophy
 Medroxyprogesterone acetate
(MPA): Return to Fertility
• resumption of ovulation
• average for 6 months to 1 year after a single injection
• median delay to conception
• 9 to 10 months after the last injection
 Medroxyprogesterone acetate:
Clinical Side Effects

• 3 months after the first injection

• 30% of women experience amenorrhea
• 30% to 40% have irregular bleeding and spotting occurring more than
11 days per month
 Adverse Effect of IUD:
Infection in the Nonpregnant IUD User

with IUD but (+) gonorrhea or chlamydia

screening tests .2
with IUD,fRve PID CDC regiment
until symptom free
• If the or if there is evidence of tubo•ovarian
abscess, the device should be; d
• give alternative method of contraception
Contraindications

• pregnancy or suspicion of pregnancy

• acute PID
• postpartum endometritis or infected abortion
• known or suspected uterine or cervical malignancy
• genital bleeding of unknown origin
• previously inserted IUD that has not been removed
• Few data: Wilson disease or an allergy to copper are true
contraindications for insertion of copper-bearing IUDs
Overall IUD Safety

reduction in risk of developing these

neoplasms(cervical and ovarian)

Laurelli, 2011: use of LNG-IUS as a fertility-sparing

treatment of early stage endometrial cancer

useful method of contraceptionfor women who have

completed their families and have contraindications to
sterilization
Subdermal Implant

•o consist of one or more thio

rods containing a„progestin
hormone
• insertion as outpatient
• skin infiltrated with local
anaesthesia 0.
• inserted superficially into the of impurit
subcutaneous tissue of the With control
implÄ1
upper arm using a tracer
• insertion site is closed with
adhesive, no need to suture
TIER 2 METHODS:

VERY EFFECTIVE
6 TO 12 PREGNANCIES PER 100 WOMEN IN 1 YEAR

INJECTABLES

PILLS
FATCH

Vaginal RING
Medroxyprogesterone acetate

• Depo-Provera, or depo-medroxyprogesterone acetate (DMPA)

• dose of 150 mg intramuscularly every 3 months

Q Search 8:46 AM
7/1712023
 Medroxyprogesterone acetate
(MPA)
• mechanisms of action:
• inhibition of ovulation by suppressing levels of FSH and LH and
eliminating the LH surge
• thickening of cervical mucus inhibiting sperm from reaching the oviduct
• altering the endometrium -> atrophy

0:46 AM
Partlysunny
Q Search
 Medroxyprogesterone acetate
(MPA): Return to Fertility
• resumption of ovulation
• average for 6 months to 1 year after a single injection
• median delay to conception
• 9 to 10 months after the last injection
 Medroxyprogesterone acetate:
Clinical Side Effects

• 3 months after the first injection

• 30% of women experience amenorrhea
• 30% to 40% have irregular bleeding and spotting occurring more than
11 days per month
 Medroxyprogesterone acetate:
Clinical Side Effects

• at the end of 1 year

• 55% of women experience amenorrhea
• after 2 years
• 70% of women experience amenorrhea
• women who use this method should receive counseling that with
time irregular bleeding will diminish and amenorrhea will most
likely occur
 Medroxyprogesterone acetate:
Clinical Side Effects
• Weight Changes
• one fourth of women using DMPA gain weight
• first 6 months of use
• DMPA users gain between 1.5 and 4 kg in the first year of use
and continue to gain weight thereafter
• No clear understanding of how this weight gain
 Medroxyprogesterone acetate:
Clinical Side Effects
• Mood Changes
• less than 5% depression and mood change
Headache
• No comparative studies indicate that DMPAincreases the incidence or
severity of tension or migraine headaches
• migraine headaches does not contraindicate DMPA use
 Medroxyprogesterone acetate:
Clinical Side Effects
• Bone Loss
• DMPA suppresses production of estradiol
• bone remodeling is increased -> resemble menopause
• observational studies consistently indicate that DMPA is associated with
a degree of decreased bone mineral density (BMD)
 Medroxyprogesterone acetate:
Clinical Side Effects
• Bone Loss
• bone loss is reversible after stopping DMPA use
• measurement of bone mineral density during DMPA use is unnecessary
• bisphosphonate therapy should not be used in DMPA users with low
BMD
 Medroxyprogesterone acetate:
Noncontraceptive Health Benefits
• reduces the risk of developing iron deficiency anemia and PID
• reduction in risk of endometrial cancer
• reduces the incidence of primary dysmenorrhea, symptoms of
endometriosis, ovulation pain, and functional ovarian cysts
because it inhibits ovulation
• reduces seizure frequency in women with epilepsy
• beneficial effects on sickle cell pain crises
 Medroxyprogesterone acetate:
Clinical Recommendations
• can be started at any time during the menstrual cycle
• make sure she is not pregnant
• if given later than 7 days into the menstrual cycle, backup
contraception should be used for 7 days
 Medroxyprogesterone acetate:
Clinical Recommendations
• Pretreatment counselling
• prior to receiving the 1st injection of the occurrence of irregular
bleeding and the development of amenorrhea
• improve continuation rates
• if pregnancy occurs in a woman receiving DMPA,the hormone
does not adversely impact the pregnancy
Oral Contraceptive Pill

most widely used methods combine EE with one of several synthetic progestins

major effect of the progestin component

to inhibit ovulation

thickening of the cervical mucus

thinning of the endometrium

major effects of the estrogen

maintain the endometrium

prevent unscheduled bleeding

to inhibit follicular development through a synergistic effect with the progestin

Oral Contraceptive Pill:
Pharmacology
• OC formulations
• progestin-only pills (POPS)
• fixed-dose (monophasic) combination pills
• contain tablets with the same dose combination of an
estrogen and progestin each day
• multiphasic combination pills
• containing severa! different dose combinations in the
same pack
• different tablet color corresponds to each dose
• biphasic, triphasic, or four phasic
 Oral Contraceptive Pill:
Pharmacology

prm•ldeaetve Pittsmntinuoudy 21 da•ts(3 weeks) by a 7-d&i tÜmone-

free interval (HR)

with in•ctwe spacer (placebo) during the HR irtproe

packaged With iron supplement in the spacer pills

qoi.iozozoto:o
o
Oral Contraceptive Pill:
Pharmacology
Uterine bleeding occurs secondary to hormone withdrawal
during the HFI
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
 Oral Contraceptive Pill:
Pharmacology
• Extended cycle regimens
• 84 days of active pills
followed by a 7-day HFI
• withdrawal bleeding only
four times a year
Oral Contraceptive Pill:
Pharmacology
1% failure rate with perfect use

8% failure rate with typical use

accidental pregnancies occurring during OC use

delayed initiation of the new cycle of medication

important that the pill-free interval is not extended more

than 7 days

misses two or more pills in a pack, use backup contraception

OCP: Mechanism of Action

• COP suppress gonadotropins

• estrogen component
• preventsa rise in FSH
• enhances the action of progestin component
OCP: Mechanism of Action

Progestin component

inhibits ovulation by inhibiting luteinizing hormone (LH) surge

by interfering with release of gonadotropin-releasing hormone

(GnRH) from the hypothalamus and pituitary

changes in the cervical mucus: prevent sperm transport into the

uterus)

the fallopian tube: interfere with gamete transport

the endometrium: reduce implantation rate

OCP: Mechanism of Action

Wlthdrawa( bleeding
• bleeding during the hormone-free interval
• it occurs upon cessation of the progestin component of the pill
• Breakthrough bleeding
• bleeding during the time that active pills are ingested
• insufficient estrogen to support the endometrium
COP: Metabolic Effects

Frequent symptoms produced by the estrogen component

nausea (12%)
breast tenderness (9%)
headache (18%)
COP: Metabolic Effects

• Frequent symptoms produced by the estrogen component

OCS decrease androgen levels, which tends to reduce

• relates to:
• the androgenicity of the progestin component
• extent that endogenous androgens circulate freely or
are bound to plasma proteins
• activity of 5 a-reductase, the enzyme that converts
testosterone to dihydrotestosterone
Progestin-Only Pills (POPS)

taken every day without a steroid-free interval

because doses of a progestin are below the ovulation

inhibition dose

counsel patients using POPS that preparations should be

consistently taken at the same time of day to ensure that
blood levels do not fall below the effective contraceptive

experience irregular bleeding, spotting, or amenorrhea

Coagulation Parameters

• increase risk of venous and arterial thrombosis

• COP offer significant protection against pregnancy which is
associated with twofold higher risk of thrombosis
Coagulation Parameters: VTE

increased risk due to the estrogen component and is dose dependent

woman's baseline risk of venous thromboembolism (VTE) increases by three

times if she ingests estrogen-containing oral contraception

Who are at risk?

personal history of idiopathic VTE

has a family history of thrombotic events

extreme obese (BMI) >40

women older than age 35 who also smoke is contraindicated due to the risk
of myocardial infarction
OCP: Return to Fertility

• suppressive effect on the hypothalamic-pituitary-ovarian axis

disappears quickly
• no risk of congenital malformations or other adverse outcomes
in pregnancies among women who conceive while taking OCS
OCP: Return to Fertility

• suppressive effect on the hypothalamic-pituitary-ovarian axis

disappears quickly
• no risk of congenital malformations or other adverse outcomes
in pregnancies among women who conceive while taking OCS
OCP: Neoplastic Risks
and Benefits
• Breast cancer
• increase by 25% but localised
' Endometrial cancer
• strong protective effect
• Cervical cancer
• conflicting
• related to the adenocarcinoma type
' does not alter the incidence or rate of the
progression of cervical dysplasia to invasive cancer
OCP: Neoplastic Risks
and Benefits

• Ovarian cancer
• decreases by about 20% for every 5 years of use
• reduces the risk of ovarian cancer in women with BRCA-I
and BRCA-2 mutations
• Liver cancer
• benign hepatocellular adenoma -> extremely rare
occurrence
• active liver disease should not use hormonal contraception
• colorectal
• 15% to 20% reduction in the risk of colorectal cancer
Noncontraceptive Health Benefits

include improvementof menorrhagia and dysmenorrhea and

decreased acne (Maguire, 2011)

reduce the amount of blood loss at the time of endometrial shedding

decreased development of iron deficiency anemia

less likely to have menorrhagia, irregular menstruation, or

intermenstrual bleeding

reduce such ovulatory disorders as dysmenorrhea and premenstrual

syndrome
 Contraindications to Oral
Contraceptive Use
• World Health Organization guidelines; medicat eligibility criteria
• Absolute contraindications
• Pregnancy
• vascular disease
• thromboembolism
• thrombophlebitis
• atherosclerosis
• stroke
 Contraindications to Oral
Contraceptive Use

• Absolute contraindications
• systemic disease that affect the vascular system
• active lupus erythematosus with vascular involvement
• diabetes with retinopathy or nephropathy
Cigarette smoking by OC users older thap age 35 and uncontrolled
hypertension
• has breast or endometrial cancer
undiagnosed uterine bleeding
elevated triglyceride levels
migraine headache with aura or peripheral neurologic symptoms
 Contraindications to Oral
Contraceptive Use

• RELATIVE contraindications
• heavy cigarette smoking youngerthan age 35
• migraine headaches without aura under 35 years
• undiagnosed causes of amenorrhea or genital bleeding
Beginning Oral Contraceptives

Adolescents
does not accelerate epiphyseal closure in the
postmenarchal female
Beginning Oral Contraceptives

After Pregnancy
after 28 weeks and are not nursing
after 6 weeks postpartum
Beginning Oral Contraceptives

Cycling Women
Sunday start
Starting a pill pack on the same day as a clinic
visit
CONTRACEPTIVE PATCH

• 75 pg ethinyf estradiol and 6 mg

norelgestromln
• applied to the skin for 3 consecutiveweeks
and no patch for the following week of a 4-
week cycle to allow withdrawal bleeding
• applied to one of four anatomic sites:
buttocks, upper outer arm, lower
abdomen, or upper torso excluding the
breasts
• steroids appear in the circulation rapidly
and reach a plateau within 48 hours
• the primary mechanism of action is the
inhibition of gonadotropin release and
prevention of ovulation
CONTRACEPTIVE VAGINAL RING

flexible ring-shaped device

containing 2.7 mg of ethinyl
estradiol and 11.7 mg of
etonogestrel Vagina)
ring
placed in the vagina for 21 days
and then removed for up to 7
days to allow withdrawal bleeding

the main mechanism of action is

inhibition of gonadotropins and
prevention of ovulation
TIER 3 METHODS

• 18 OR MORE PREGNANCIES PER 100 WOMEN IN 1 YEAR

• BARRIER METHODS
• LACTATIONALAMENORRHEA
• PERIODIC ABSTINENCE
• COITUS-RELATED METHODS
BARRIER METHODS

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

If repeated intercourse takes place,

additional spermicide should be used
vaginally
Uterus
Failure rate 1st year of use for the Contraceptiw
diaphragm ranges from 13% to 17% Cenix
among all users and may be as low as
4% to 8% with perfect use

0
Cervical
Reduce the risk of cervical dysplasia and
cancer

Cervical
cap
Vagina
 BARRIER METHODS:
Male Condom
should be applied to the erect penis before any contract with the
vagina or vulva

tip should extend beyond the end of the penis by about half an
inch to collect the ejaculate

After ejaculation, the penis must be removed from the vagina

while still somewhat erect, and the base of the condom grasped
to ensure the condom is removed without spillage of the
ejaculate

Water-based lubrication may reduce condom breakage

 BARRIER METHODS:
Female Condom
soft, loosetting polyurethane
sheath with two exible rings

one ring lies at the closed end Closed

of the sheath and serves as an
insertion mechanism and
internal anchor for the
condom inside the vagina
Foote
 LACTATIONALAMENORRHEA
METHOD (LAM)
Prolactin inhibits gonadotropin pulsatility, nursing women typically remain
amenorrheic for a variable length of time after giving birth

Criteria for successful use of LAM

continuous amenorrhea
exclusive breast-feeding (no supplements) for up to 6 months after delivery

night nursing is highly protective

failure rate first 6 months postpartum is less than 2%.

PERIODIC ABSTINENCE

• Avoidance of coitus at the time ovum can be fertilised

• Highly motivated couple
• Four methods:
Calendar/Rhythm
Temperature
Cervical mucus method
Symptothermal
Calendar/Rhythm

• Fertile period based on length of cycles

• MUST have REGULAR monthly cycles
• Observe cycle for 6 months
• Shortest cycle subtract 18 and longest cycle subtract 11
• Shortest cycle 24 days-18 = 10
• Longestcycle28 days- 11 = 17
• Couple abstains during the estimated fertile period
• DAYS 17
Temperature

NFP: Client Instructions for BBT Method

Thermal Shift Rule:

• Take temperatureat about same time each morning (before
rising) and record temperature on chart provided by NFP
Instructor.
• Use temperatures recorded on chart for first 10 days of
menstrual cycle to Identify highest of "normal, low"
temperatures (i.e., daily temperatures charted in typical pattern
without any unusual conditions).
Disregard any temperatures that are abnormalty high due to
fever or other disruptions.
• Drawa line 0.05-0.10 C above highest of these 10
temperatures. This line is called the cover line or temperature
line.

13
Temperature
AS

Basal Body TemperatureMethod

990

Ovulation
enstruation Menstruation
980

97.0
10 15 20 25 30 35

Day of cycle
Cervical mucus method

• Recognition of changes in cervical mucus consistency

• Abstinence or barrier on the first day of copious slippery mucus

then the couple abstains daily until 4 days after the last day
when the characteristic mucus was observed
"wet" = ABSTAIN
"dry" = SAFE PERIOD
Symptothermal
Symptothermal

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 COITUS-RELATED METHODS:
Spermicides
active agent is a surfactant that
immobilizes or kills sperm on contact by
destroying the sperm cell membrane

must be placed into the vagina before

each coital act, often in combination with
a barrier contraceptive

contraceptive sponge, a cylindric piece of

soft polyurethane impregnated with 1 mg
of nonoxynol-9 spermicide

must be inserted into the vagina before

intercourse

effective for 24 hours.

failure rate ranges from 15% to 25%

COITUS-RELATED METHODS:
Coitus Interruptus (Withdrawal)
can fail because of the small numbers of sperm present in some
pre-ejaculate