CME:

CONTRACEPTION

Presenters:
1. STEPHANIE SONIA
2. ABDUL SIDDIQ
1
3. MELISSA KUEH
4. NOOR SYAHIRA
 What is Contraception?

Prevention of conception or impregnation by interfering with the normal

process of ovulation, fertilization and implantation.

Characteristic of Ideal Contraceptive Method

Independent of
intercourse and
Highly effective No side effects or risks Cheap requires no regular
action on the part of
user

Easily distributed and

Non-contraceptive Acceptable to all administrated by
benefits cultures and religions non-healthcare
personnel

3
 METHODS OF CONTRACEPTION
Types Examples
1. Combined hormonal a. Pill
contraception b. Patches
c. Vaginal ring

2. Progestogen-only a. Pill
contraceptive methods b. Subdermal implants
c. Injectables

3. Intrauterine contraception a. Copper intrauterine devices (Cu- IUD)

b. Levonorgestrel- releasing intrauterine system (LNG- IUS)

4. Barrier methods a. Condom

b. Diaphragm and cap
c. Spermicides

5. Fertility awareness-based a. Calendar or rhythm method

methods (FAB) b. Temperature method
c. Cervical mucus method
d. Cervical palpation
e. Personal fertility monitor

6. Sterilization a. Female sterilization

b. Vasectomy

7. Lactational amenorrhoea -

8. Emergency contraception -
COMBINED HORMONAL
CONTRACEPTION
Pills
Transdermal patch
Vaginal ring
COMBINED HORMONAL
CONTRACEPTION
▪ Contain 2 hormones: Oestrogen & Progestogen
▪ MOA:
a. Suppression of ovulation
Inhibit ovulation via negative feedback of oestrogen and progestogen on the pituitary,
with suppression of follicular- stimulating hormone (FSH) and luteinising hormone
(LH).
b. Thicken the cervical mucus – reduce sperm penetrability
c. Thinning of the endometrium – reducing likelihood of implantation
1. COMBINED ORAL CONTRACEPTIVE PILLS
▪ Mode of action
▪ Combined oral contraception acts both centrally and peripherally.
▪ Central effect: inhibit ovulation
▪ Peripheral effects:
▪ making the endometrium atrophic and hostile to implantation
▪ altering cervical mucus to prevent sperm ascending into the uterine cavity
• Ethinyl oestradiol (15-35ug) + 2nd generation progestogens (levonorgestrel,
norethisterone)
• 21 pills + 7-day pill free interval (or 7 placebo tablets)
 COMBINED ORAL CONTRACEPTIVE
PILLS
When to START?
✔ Any time in menstrual cycle if sure of absent pregnancy

✔ Once a day at the same time everyday (21/7) – one pill daily, followed by 7 days pill free
interval/ placebo pills
✔ If missed pill (depend on quantity missed), she may :
Take most recent missed pill as soon as she remembers
Continue the remaining at usual time
May require additional contraceptive protection/emergency contraceptive

When to stop…??
✔ Sudden appearance of headache, numbness, chest pain, breathlessness, speech
disturbances, jaundice
✔ Stop at least 4 weeks before elective pelvic or leg surgery –risk of VTE
 COMBINED ORAL CONTRACEPTIVE PILLS
Advantages:
• Safe and more than 99% effective
if used correctly
• Reversible
• Does not interrupt sexual
intercourse
• Decrease menorrhagia,
dysmenorrhea & risk of PID
• COC also offers long term
protection against both ovarian and
endometrial cancers.
• Improve menopausal symptoms
Disadvantages:
• Require daily uptake, risk of missed pills
• Temporary side effects at first, such as
headaches, nausea, breast tenderness and
mood swings
• Does not protect against STI
• Breakthrough bleeding and spotting is
common in the first few months of using the
pill
• Thromboembolic risk (DVT, Stroke, MI) –
due to estrogen’s affect on clotting factors &
arterial disease
• Breast cancer
 COMBINED ORAL CONTRACEPTIVE PILLS –
CONTRAINDICATIONS
Absolute contraindications Relative contraindications
▪ <6 weeks postpartum and
▪ Controlled Hypertension
breastfeeding
▪ Obesity, Dyslipidemia
▪ Smoking ≥15 cigarettes/day and age
≥35 ▪ Breast CA with >5 years without
▪ History of stroke/ ischemic heart recurrence
disease
▪ Breastfeeding until 6 months
▪ Uncontrolled hypertension postpartum

▪ Current or history of DVT/pulmonary ▪ Current or medically treated

embolism gallbladder disease
▪ Major surgery with prolonged ▪ Mild cirrhosis
immobilization
▪ Taking rifampicin or certain
▪ Migraine with aura
anticonvulsants
▪ Current breast CA
 SIDE EFFECTS OF COCP

▪ Psychological: Mood swings, depression, headache

▪ Decreased libido
▪ Nausea
▪ Perceived weight gain
▪ Bloatedness
▪ Increase vaginal discharge & breakthrough bleeding
▪ Engorged and pain of breasts
▪ Chloasma (facial pigmentations)
▪ Increase risk of developing breast cancer
MISSED PILL GUIDELINES
2. COMBINED HORMONAL PATCHES
▪ Ethinyloestradiol (33.9ug/day) + Norelgestromin (203ug/day)
▪ Patches are applied for 21days, followed by a patch-free week (7days)
▪ Applied to skin of lower abdomen, buttock or arm
▪ Cons: relatively more expensive than COCP, problems with patch
adherence, skin sensitivity
▪ Pros: better compliance than COCP
 3. COMBINED HORMONAL-VAGINAL
RINGS
▪ Flexible ring, 54mm in diameter
▪ Releases ethinylostradiol (15ug) + etornogestrel (120ug)
▪ Self inserted in vagina for 21 days, followed by 7 days hormone-free
 Progestogen-only
Contraceptive Methods
Pill
Subdermal implants
Injectables
 PROGESTOGEN ONLY PILLS

Mode of action:
▪ Prevent sperm penetration by thickening and hostilation of
cervical mucus
▪ Prevent implantation by thinning of endometrium
 1. PROGESTOGEN-ONLY PILL

▪ If a POP is missed
▪ continue taking the POP and
▪ use extra precautions (e.g. condoms) for the next 48 hours until the
progestogen effect on the mucus is built up.
▪ If unprotected sex occurs during this time, then emergency contraception
is required.
● Indication ● Contraindication
● Breast feeding ● suspected pregnancy
● Older age ● breast cancer
● undiagnosed vaginal
● Medical
bleeding
condtion(HPT,VTE)
ADVANTAGES
▪ Avoid risk and side effect of estrogen
▪ Does not interrupt sex
▪ Can be used it when breastfeeding
▪ Useful if cannot use the hormone
oestrogen, which is in the combined
pill, contraceptive patch and vaginal ring
▪ Can be used it at any age (over 35 years
old)
▪ Safe for those with cardiovascular risk
factors (old women, smoke)
DISADVANTAGES
▪ May not have regular periods while taking
it – periods may be lighter, more frequent,
or may stop altogether, and you may get
spotting between periods
▪ Does not protect against STI
▪ Need to remember to take it at or around
the same time every day
 SIDE EFFECTS

▪ Progestogen side effects

▪ Irregular bleeding

▪ Compliance issue

▪ Acne

▪ Breast tenderness and breast enlargement

▪ An increased or decreased sex drive

▪ Mood changes

▪ Headache and migraine

▪ Nausea or vomiting

▪ Small fluid-filled sacs (cysts) on your ovaries – these are usually harmless and disappear
without treatment
 2. SUBDERMAL IMPLANT
▪ Contain etonorgestrel in a rod
▪ Act by thickening of cervical mucous.
▪ Can be used for three years by implanting rod under the skin (at the middle
part of arm)
▪ Indications:
▪ Women who have difficulty remembering to take a pill regularly
▪ Who want high effective long-term contraception

▪ Contraindications:
▪ Known or suspected pregnancy
▪ Acute DVT or PE
▪ Liver tumors, benign or malignant, or active liver disease
▪ Undiagnosed abnormal genital bleeding
▪ Known or suspected breast cancer, personal history of breast cancer, or
other progestin-sensitive cancer, now or in the past
▪ Allergic reaction to any of the components of Implanon
Advantages: Disadvantages:
• very affective • difficult to remove
• safe • bruises
• easy to use • progesterone side effect
• long term effect (irregular breathing)
• not affecting sexual
intercourse
• fertility stored immediately
after removal
▪ Side effects:
o Changes in Menstrual Bleeding Patterns
o Ectopic Pregnancies
o Thrombotic and Other Vascular Events
o Liver Disease
3. PROGESTOGEN-ONLY
INJECTABLE
Depot injection of
medroxyprogesterone
acetate

Intramuscular
(Buttocks, upper arm, Subcutaneous
lower abdomen)

Depoprovera (150mg) Sayana press (104mg)

 PROGESTOGEN-ONLY INJECTABLE

▪ MOA: Prevent fertilization by thickening of cervical mucous and

thinning of uterine wall

▪ Both intramuscular and subcutaneous preparations have similar

features:
ADVANTAGES DISADVANTAGES

▪ Good for ‘non ▪ Delayed return of fertility

compliance’ patient after discontinuation
▪ Injection can be taken ▪ Gain of weight
early or late 7 days
▪ Increase risk of
▪ Good for birth spacing osteoporosis
▪ Can be taken during ▪ Amenorrhea
breastfeeding ▪ Irregular bleeding
▪ Does not affect sexual ▪ Progestogen side effects
intercourse
Contraindications:
▪ Liver disease
▪ Current breast cancer
▪ Unexplained uterine bleed
▪ pregnancy
Side effects:
▪ Delay return of fertility after
discontinuation (May take up to 1
year)
▪ Weight gain
▪ Loss of bone mineral density-
reversible on stopping
▪ Irregular/ absent menstrual
bleeding
INTRAUTERINE CONTRACEPTION
Cu-IUD
LNG-IUD

Copper Mirena
Advantages Disadvantages
• Highly effective • Not recommended for
• Reversible women with STD
• Not cost effective for
short-term used
• Abnormal bleeding ,
amenorrhea

Contraindication of IUCD:
1.Pregnant
2. Uterine anomalies
3. Pelvic infection
4. Unexplained abnormal genital bleeding
5. Endometrial or cervical cancer
6. Wilson’s disease or copper allergy
Complication of IUCD

1. Risk of infection , Lower in MIRENA as the thickened cervical

mucus. Inert IUD can lead to actinomycosis infection
2. Bleeding
3. Ectopic pregnancy
4. Expulsion
5. Translocation
Barrier Contraception
Condoms
Diaphragm and cap
Spermicides
MALE CONDOM

▪ Latex, cheap and widely available

▪ Advantages:
▪ Protect against STI including HIV
▪ Only reversible male method
▪ No prescription needed
▪ Easily available and harmless

▪ Disadvantages:
▪ Typical failure rates are 24% since they rely on the user to put it on correctly
▪ Breakage
FEMALE CONDOM

▪ Lubricated polyurethane condom that is inserted into the vagina

▪ Internal ring in the closed end of the pouch covers the cervix
▪ External ring remains outside the vagina, partially covering the perineum
▪ Advantages:
▪ Protects against STIs
▪ No medical condition limits the use of it.
▪ Offers greater protection as it covers external and internal
genitalia.
DIAPHRAGM & CAP

▪ Latex/non-latex devices that are inserted into the vagina to prevent

passage of sperm to the cervix
▪ Inserted in advance of sex
▪ Cap fits over the cervix
▪ Diaphragms form a hammock between the post-fornix and the
symphysis pubis.
▪ Often used in conjunction with a spermicide.

36
37
38
Disadvantages :
▪ Women need to be taught how to insert and remove the device
▪ Typical failure rates – 18%
▪ Increased vaginal discharge
▪ Urinary tract infections

Cervical Correct sitting of cap

cap
SPERMICIDES

▪ Spermicide alone is not recommended for

prevention of pregnancy – low
effectiveness
▪ Nonoxynol 9 (N-9) – sold as gel, cream,
foam, sponge or pessary for use with
diaphragms or caps
▪ Frequent use of N-9 increase the risk of
HIV transmission
▪ No longer recommended for women who
are high risk of HIV infection
Sterilization
Female sterilization
Vasectomy
 FEMALE STERILIZATION

▪ Permanent method of contraception, prevents sperm reaching the

oocyte in the Fallopian tube
▪ Can be performed by:
▪ Laparoscopy
▪ Hysteroscopy
▪ Laparotomy ( eg. at caesarean section)
 LAPAROSCOPIC STERILIZATION

▪ Occludes the Fallopian tube with filshie clips

▪ Effective contraception should be used until the next menses after the
procedure, d/t risk of pregnancy from implantation of an early fertilized egg in
the same cycle as sterilization
▪ Women with higher surgical risk (obesity/previous abdominal surgery), do
hysteroscopic approach
▪ Sterilization at the same time as caesarean section must be counselled and give
consent
▪ Since sterilization results in permanent loss of fertility and involves a surgical
procedure, it is important that valid consent is obtained.
 HYSTEROSCOPIC STERILIZATION

▪ Can be performed as outpatient procedure (without GA)

▪ Microinserts (Essure), expanding springs (2 mm diameter, 4cm in length) made of
titanium, steel and nickel containing Dacron fibres are inserted into the tubal ostia
via a hysteroscope
▪ These induce fibrosis within the corneal section of each fallopian tube over the
following 3 months.
▪ Contraception is required during the 3 months and can only be discontinued once
correct placement of the inserts are confirmed by Xray or ultrasound.
 ADVICE TO WOMEN CONSIDERING
STERILIZATION

▪ Method is considered as irreversible.

▪ Failure rate 1:200 for laparoscopic, 1 :500 for hysteroscopic (comparable
to long-acting reversible methods).
▪ Risks and complications (laparoscopic 1:1000 risk of trauma to bowel,
bladder or blood vessels)
▪ Vasectomy is safer, quicker and with less morbidity.
▪ High proportion of women regret sterilization. Risk factors are age under
30 years, nulliparity recent pregnancy (birth, abortion, miscarriage) and
relational issues.
▪ Does not protect against STIs.
▪ Effective contraception is required until the menstrual period following
laparoscopic procedure or 3 months following hysteroscopic procedure.
▪ Pregnancy following female sterilization is rare but if it does occur there
is an increased risk of ectopic.
▪ Reversal of sterilization is highly skilled procedure to obtain tubal
reanastomosis. It cannot be performed after hysteroscopic sterilization,
and if it is successfully conducted after laparoscopic sterilization, it is
associated with an increased risk of ectopic pregnancy.
 VASECTOMY

▪ Interrupt the vas deferens to provide permanent occlusion

▪ ‘No scalpel’ vasectomy - a puncture wound in the skin of the scrotum
under LA to access and then divide and occlude the vas using cautery
▪ Small risk of a scrotal haematoma and infection
▪ Post vasectomy semen analysis should be conducted at 12 weeks to
confirm the absence of spermatozoa in the ejaculate
▪ The failure rate is significantly less than female sterilization at
approximately 1 in 2,000.
Fertility Awareness-Based
Methods (FAB)
Calendar or rhythm method
Temperature method
Cervical mucus method
Personal fertility monitor
 FAB

▪ Formerly known as ‘natural family planning‘

▪ Rely on the signs and symptoms that reflect the physiological
changes
▪ Requires motivation and regular menstrual cycle, cannot be used
for women at extremes of reproductive age.
▪ Typical failure rates are high
Calendar or rhythm method
▪ Fertile days are calculated based
upon the cycle length recorded over
at least 6 cycles.
▪ First fertile day = shortest cycle minus
20.
▪ Last fertile day = longest cycle minus
10.
▪ For women with 28 day cycle this
equates to abstinence for 10 days in
each cycle (day 8-18)
Temperature method
▪ Increase in basal body temperature
(0.2 -0.4 C) produced by the rise in
progesterone following ovulation.
▪ Daily temperatures must be measured
using the same route.
▪ Infection, exercise and some
medications can affect body
temperature and interfere with this
method.
 CERVICAL MUCUS METHOD

▪ Mucus on toilet tissue after wiping the

vulva can be examined for consistency.
▪ Midcycle ‘fertile’ mucus due to rising
oestradiol levels is clear, watery and
slippery rather like raw egg white.
▪ Following ovulation, progesterone
renders it thick and opaque.
▪ Semen in the vagina may make it
difficult to recognize the mucus.
 PERSONAL FERTILITY MONITOR

▪ Hand-held monitor analyses disposable urine dipsticks that record the

presence of metabolites of oestrogen and LH in the urine.
▪ Recognizes urinary oestrogen concentrations corresponding to the
midfollicular phase of the cycle and preovulatory LH peak, so that
beginning and end of fertile phase can be identified.
▪ Red light – fertile phase, usually shown for 6-10 days in the cycle
▪ Green – infertile
▪ Users need to perform urine dipstick tests on early morning urine.
 LACTATIONAL AMENORRHOEA
▪ First 6 months of postpartum – amenorrhoeic, fully/nearly fully
breastfeeding, risk of pregnancy is about 2%
▪ After 6 months, or if menses occur or breast feeding reduced,
then another method of contraception must be used.
 EMERGENCY CONTRACEPTION

▪ Most effective method of EC is an IUD (99% effective)

▪ IUD can be inserted up to 5 days after ovulation for EC
▪ Ulipristal acetate (UPA), progesterone receptor modulator or
levonorgestrel (LNG) - oral EC
▪ UPA - within 120 hours of unprotected intercourse
▪ LNG - within 96 hours of unprotected intercourse
▪ Effective ongoing contraception should be started after EC
 FAILURE RATE OF CONTRACEPTIVE
METHODS

Table above shows : Percentage of women experiencing an unintended pregnancy within

the first year of use with typical use and perfect use.
THANK YOU