CONTRACEPTION

WHAT is CONTRACEPTION?
the prevention of unwanted pregnancy
Prevent ovulation Prevent fertilization of ovum Prevent implantation of fertilized ovum

WHY use CONTRACEPTIVES?

TO AVOID PREGNANCY / CONCEPTION
- Pregnancy in women > 40 years
associated with: maternal morbidity/ mortality perinatal mortality chromosomal abnormality (e.g.: Downs Syndrome)

- To avoid hereditary disorders (e.g.: Thalassemia) - For spacing of children - Not ready (financial / mental / physical)

WHO uses CONTRACEPTION?

Individuals in a sexual relationship
WHO PRODIGY guidance for contraception:

12-60 years old

According to UK National Statistics 2003:

74% of women aged 16-49 use at least 1 form of contraception

The most commonly used methods:

Oral Contraceptive Pills 25% Male/Female Sterilization 23% Male Condoms 20%

TYPES of CONTRACEPTION
Prevent ovulation
Oral / Hormonal Contraceptives
(COCP, POP, IM Depot)

Prevent fertilization of ovum

Coitus interruptus Barrier method
(condom, female diaphragm, sterilization)

Prevent implantation of fertilized ovum

IUCD Emergency contraception

Misc
Rhythm method

EFFICACY of CONTRACEPTION
Method of Contraception

User Failure 5% 5% 0.3% 27% 21% 15% <1%

0.5%
1:200 lifetime

Method Failure 0.1% 0.5% 0.3% 4% 5% 2% <1%

0.5%
1:200 lifetime

COCP POP IM DEPO Withdrawal

Female Condom Male Condom

IUCD
Female Sterilization Male Sterilization
*within FIRST year of use

0.15%
1:700 lifetime

0.10%
1:1000 lifetime

WHICH CONTRACEPTION?
Highly effective No side effects Independent of intercourse Rapidly reversible Cheap Widespread availability Acceptable to all cultures & religions Administration by healthcare personnel not required Easily distributed

COMBINED ORAL CONTRACEPTIVE PILL (COCP)

COCP - Introduction
Synthetic ESTROGEN + PROGESTERONE
Estrogen : usually ethinylestradiol Progesterone : 2nd gen levonorgestrel, norethisterone 3rd gen desogestrel, gestodene > 99% effective if used correctly

COCP Mode of Action

Inhibition of ovulation
FSH & LH

Thickening of cervical mucus

Preventing sperm penetration

Reduction of endometrial receptiveness

COCP - Method
May be used from menarche menopause Start on day 1 of menses Take everyday for 21 days, within 12 hours of the same time everyday Pill-free for 7 days (allow menses) Missed pill: emergency contraception needed only if no previous 7-day protection

COCP - Advantages
Highly effective Reversible Menstrual pain & blood loss
(Lyer et al 2003, Proctor et al 2003, Moore et al 2003)

Possible protection against PID

(Cramer et al 1987, Panser & Philips 1991)

Possible protection against osteoporosis

(Berenson et al 2001, Wanichsetakul et al 2002)

risk of ovarian & endometrial CA

Risk is reduced by 50% if COCP used > 1 year Mortality is also reduced
(Vessey et al 2003)

Effect will persist for up to 15 years after stopping

(IARC 1999)

COCP - Disadvantages
Breast tenderness Acne Mood changes
Irritability, emotionally unstable

Weight gain risk of Venous thromboembolism (5X), Myocardial infarction (HPT, smoking = 3-10X) Stroke (2-3X) Cervical CA (< 5 years = 10%) ( 10 years = 100%) Breast CA (small risk) Liver CA (small risk)

COCP - Contraindications
< 6 weeks postpartum
Risk to neonate due to steroid exposure

> 6 months postpartum

Diminished quality of breast milk Decreased duration of lactation

Aged > 35 years + smoking History of HPT, CVS d/o, CVA, Liver d/o, Breast d/o, Migraine

PROGESTERONONLY PILL (POP)

POP - Introduction
Contains low-doses of:
Norethisterone Etynodiol diacetate Levonorgestrel Desogestrel

Alternative for women who cannot take estrogen due to CVA, CVS, Migraine

POP Mode of Action

Inhibition of ovulation
FSH & LH

Delayed ovum transport Thickening of cervical mucus

Preventing sperm penetration

Reduction of endometrial receptiveness

POP - Method
Started on 1st day of period Taken continuously everyday WITHOUT BREAK Taken within 3 hours of the same time everyday Missed pill: added contraceptive for 2 days

POP - Advantages
Reliable Reversible Can be used by women who cannot use estrogen

POP - Disadvantages
Menstrual irregularities Strict time window Development of functional ovarian cysts risk of breast CA

POP - Contraindications
Breastfeeding < 6 weeks postpartum History of breast CA History of liver d/o

INTRAMUSCULAR DEPOT INJECTION (IM DEPO)

IM Depo - Introduction
Progesterone-only injection Commonest: Medroxyprogesterone acetate (Depo Provera) Provides contraception for 12 weeks

IM Depo Mode of Action

Inhibition of ovulation
FSH & LH

Thickening of cervical mucus

Preventing sperm penetration

Reduction of endometrial receptiveness

IM Depo - Method
IM injection by a trained medical staff

IM Depo - Advantages
Highly effective Ensured compliance Protect against functional ovarian cysts

IM Depo - Disadvantages
Must be given as a deep IM injection Delay in return to fertility Irregular menstrual cycles after withdrawal Weight gain Reduction in bone mineral density
(reversible)

risk of breast CA

IM Depo - Contraindications
History of breast CA Breastfeeding < 6 weeks postpartum History of liver d/o

INTRAUTERINE CONTRACEPTIVE DEVICE (IUCD)

IUCD Introduction
Polyethylene + Copper With monofilament thread to check that the IUCD is still in place & for removal Usually left in situ for 3 years

IUCD Mode of Action

Prevention of fertilization Copper ions also alter the biochemical processes & enzymes involved in implantation

IUCD - Method
Inserted after confirming there is no pregnancy Can be inserted anytime Usually inserted:
Within 7 days of start of menses Within 4 weeks postpartum if non-lactating Within 6 months postpartum if lactating
(reduced risk of uterine perforation d/t oxytocin)

IUCD - Advantages
Highly effective Reversible Immediate No drugs can affect its efficacy

IUCD - Disadvantages
Menstrual abnormalities
1st 3-6 months

Unacceptable bleeding, dysmennorrhoea leading to IUCD removal Small risk of pelvic infection (post 20 days) IUCD expulsion (1:20) Uterine perforation (< 1:1000)

IUCD - Contraindications
Pregnancy Breastfeeding Anatomical abnormalities Cervical / Endometrial / Ovarian d/o PID STDs