Family Planning

FEU-NRMF Medical Center

 LEARNING OBJECTIVES
• Justify the importance of family planning
and contraception.
• Define typical use and perfect use.
• List down all the methods o0f
contraception from most effective to
least effective.
• Explain factors which affect contraceptive
effectiveness.
• Describe the manner of action of spermicides and
their use.
• Describe the different forms of barrier techniques
and their manner of action.
• Explain how these various barrier forms are utilized.
•  
•  
• Enumerate advantage and disadvantages
of each barrier technique.
• Explain periodic abstinence, its form
( billing, BBT, symptothermal, calendar,
etc..) and their rationale behind its utility.
• Explain why periodic abstinence has high
failure rate.
• List down the different types of oral
contraceptives.
• Explain the mechanism of action of the
various contraceptive pills.
• Elaborate on the following effects of OCP:
– Side effects
– Protein metabolism
– Carbohydrate metabolism
– Lipid metabolism
– Coagulation parameters
– CVS
– Reproductive system
– Neoplastic side effects
• Given cases, determine the appropriateness
or inappropriateness of OCP:
– Indications and contraindications
– Drug interactions
• Formulate an adequate follow up scheme on
women on OCP.
• Tabulate the noncontraceptive health benefit
derived from use of OCP.
• Describe the different forms of Long
Acting Contraceptive Steroids.
• Explain the manner of action of the
different long acting contraceptive
steroids.
• Describe the effect of long acting
contraceptive steroids in the return of
fertility of users.
• Elaborate on the side and adverse
effects of long acting contraceptive
steroids.
• Given case, determine the
appropriateness or inappropriateness of
long acting OCP.
• Described how emergency contraceptive
is administered.
• Enumerate the types of emergency
contraceptive and various side effects.
• Illustrate the different types of IUDs.
• Explain the mechanism of action of the
IUDs.
• List down the advantages and advantages
of the IUD, contraindications and adverse
effects.
• Instruct patient regarding IUD insertion-
preparation, manner, timing and
important precautions.
• Select appropriate candidates for IUD
given cases.
• Describe male and female sterilization.
• Explain the side and benefits of
sterilization.
• Select appropriate candidates for
sterilization given theoretical cases.
 Reversible Methods
• Spermicides
• Barriers
• Oral Contraceptive Pills
• Long Acting Hormonal Contraception
• IUD or IUS
 Permanent
• Vasectomy
• Bilateral Tubal Ligation
 Contraceptive Effectiveness
• Typical Use Effectiveness (Use)
• Perfect Use Effectiveness (Method)
• Contraceptive Failure Rate
• Pearl Index
 Spermicides
• Gels, foams and suppositories
• Active agent : nonoxynol-9
• Coitus- related
• Used with barriers
Spermicides: Adverse Effects
• No increased risk for congenital
malformations or chromosomal
anomalies
BARRIER METHODS
 DIAPHRAGM
• Needs fitting for the appropriate size
• Patient Instructions for insertion and
removal
• Must cover cervical os totally
• Used with spermicide
• Left in place for 8 h after last coitus
 Diaphragm: Advantages
• Safe, reversible
• Married, motivated women
• Failure rates decrease with age and
duration of use
 Diaphragm: Adverse Effects
• UTI
• Vaginal epithelial ulcerations
 CERVICAL CAP
• Cup shaped rubber device fitted to the
cervix
• Needs fitting (comes in 3 sizes)
• Used with spermicides
• Not left in place beyond 48h
• Failure rates similar to diaphragm
 CERVICAL CAP
• Normal cervical cytology required
• Pap test three months after
 Cervical Cap: Advantages
• Safe and reversible
• Good continuation rates
• Placed longer than diaphragm
• More comfortable
Cervical Cap: Adverse effects
• If left in place >48h:
mucosal ulcerations
unpleasant odor
infection
• Adverse effects on cervical tissue
 MALE CONDOM
• Latex, polyurethane, or animal tissue
• Most effective contraceptive method to
prevent transmission of STDs (latex,
polyurethane)
• Males with multiple sex partners
• Correct use and careful removal
 Male condom: Advantages
• Safe, reversible
• Prevent STD transmission
• Highly effective for motivated user
Use a new condom for each act of vaginal,
anal, or oral intercourse.
Use the condom throughout sex- from start to
finish.
Put on the condom as soon as erection occurs
and before any vaginal, anal, or oral contact
with the penis.
Hold the tip of the condom and unroll it onto the
erect penis, leaving space at the tip of the
condom, yet ensuring that no air is trapped in
the condom’ s tip.
Adequate lubrication is important to prevent
condom breakage, but use only water-
based lubricants, such as glycerine or
lubricating jellies available at any pharmacy.
NEVER use oil-based lubricants such as
petroleum jelly, cold cream, hand lotion, or
baby oil, which can weaken the condom.

Withdraw from the partner immediately after

ejaculation, holding the condom firmly to the
base of the penis to keep it from slipping off.
Condom users should make sure that the
condom expiration date has not passed or
the manufacturing date does not indicate
the condom is too old (if the package is
not opened, condoms are good up to 5
years after the manufacture date).
 FEMALE CONDOM
• Loose fitting soft sheath with two
polyurethane rings
• Inner and outer rings
• Prelubricated
• Single use only
Female Condom: Advantages
• Fitting not needed
• Can be inserted before starting sex
• Can be left in place for a longer time
after ejaculation
• Additional protection for external
genitalia
• Less likely to rupture than male condom
• Also reduces risk for HIV and HPV
 Barriers: Advantages
• Reduction of STD transmission
especially if used with spermicides
• Protection against salpingitis and
cervical neoplasia
Periodic Abstinence
 Periodic Abstinence
• Avoidance of coitus at the time ovum
can be fertilized
• Highly motivated couple
• Four methods:
Calendar/Rhythm
Temperature
Cervical mucus
Symptothermal
 Calendar/Rhythm
• Fertile period based on length of cycles
• Shortest cycle-18 and Longest cycle-11
• Couple abstains during the estimated
fertile period
 Calendar
• If shortest cycle is 27 and longest cycle
is 32, what is the woman’s fertile
period?
27-18=9 and 31-11= 20

Fertile period is from days 9 to 20 and

couple should abstain or use barriers at
this time
 Temperature
• Daily monitoring of temperature
• Coitus NOT done or a barrier is used
from onset of menses until 3rd
consecutive day of elevated
temperature
• No longer used alone
 Cervical Mucus/Billing’s
• Recognition of changes in cervical
mucus consistency
• Abstinence or barrier during the menses
and every other other day after menses
end until 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.
 Symptothermal
• Calendar + cervical mucus to establish
first day of fertile period
• Temperature method to establish last
day
 Enzyme Immunoassay
• Urinary estrogen
• Pregnandiol glucoronide
Periodic Abstinence: Advantages
• Safe, reversible, affordable
• No pharmacologic side effects
Periodic Abstinence: Disadvantages

• Require highly motivated couple

• Higher failure and discontinuation rates
• Long period of abstinence
• Regular cycles (calendar)
Oral Contraceptive Pills (OCPs)
 OCPs
• Most widely used reversible method
• Estrogen + Progestin
• Progestin only (minipill)
• Currently: low dose formulations
 OCP Formulations
• Fixed Dose Combination
E + P per tablet
21 active
7 inert or pill-free days (Withdrawal
bleeding)
 OCP Formulations
• Combination phasic (multiphasic,
biphasic, triphasic)
2-3 different dose of E +P
Tablets of same dose given for 5-11
days in the 21 medication period
Not found to have advantage over fixed
dose
 OCP Formulations
• Daily progestin/minipill
low dose progestin
taken daily at the same time
no steroid free interval
ideal for nursing mothers
 Estrogen in the OCP
• Ethinyl estradiol
• Mestranol
 Progestin in the OCP
• Levonorgestrel and derivatives
(norgestimate, desogestrel, gestodine)
• Norethindrone, norethindrone acetate,
Norethynodiol,ethinodiol diacetate
 OCP generations
• First
• Second
• Third
 OCP: Mechanism of Action
• Inhibition of midcycle gonadotropin
surge and prevention of ovulation (more
consistent for combined than minipill)
• Progestin action- thick, viscid, scanty
cervical mucus ; impaired transport of
ovum and sperm; alters endometrium
 OCPs: Adverse Effects
• Metabolic
• Cardiovascular
• Reproductive
• Neoplastic
 Metabolic effects
• Estrogen Component
nausea, breast tenderness, fliud
retention
minor changes in levels of some
vitamins
melasma
mood changes and depression
irregular bleeding
headaches
 Metabolic Effects
• Progestin Component
androgenic effects (weight gain, acne,
nervousness)
adverse mood changes and tiredness
failure of withdrawal bleeding
irregular bleeding
headaches
 Protein Metabolism Effects
• Increased hepatic globulin production
(estrogen)
factors V,VIII, X, fibrinogenthrombosis
angiotensinogen BP elevation
SHBG
 Protein Metabolism Effects
• Androgenic progestins
decreased SHBG
 CHO Metabolism Effects
• Related to dose, potency, structure of
progestin
• Higher dose potencies and
dosegreater impairment of glucose
metabolism
• Gonanes (LNG and derivs)>Estranes
(Norethindrone and derivs)
 Lipid Metabolic Effects
• Estrogen
increase: HDL, total cholesterol,TGs
decrease:LDL

• Progestin
increase:LDL
decrease: HDL, total cholesterol,TGs

Newer derivatives of LNG- less androgenic,

more lipid friendly
 Coagulation Parameter Effects

• Estrogen
increase: some coagulation factors (e.g.
fibrinogen) enhances thrombosis
this is dose dependent
 CVS Effects
• Venous thromboembolism-risk is
greater for higher doses (>50µg)
of estrogen
• Myocardial infarction-no evidence of
increased risk of MI from
atherosclerosis
• Stroke-conflicting results, No increased
risk for past users compared to never
users
 Reproductive Effects
• No permanent infertility
• HPO suppression is temporary and
reversible
• Length of delay of return to fertility
related to estrogen dose and user age
not duration of use
• Pregnancy immediately after D/C not
associated with higher abortion or
anomaly rates
 Neoplastic Effects
• Breast Cancer- no significantly higher
risk compared to never users
• Cervical Cancer- uncertain, conflicting
evidences
• Liver adenoma-high dose mestranol
formulations
 Absolute Contraindications
• History of vascular disease
• Systemic diseases affecting vascular system
• Smokers older than 35
• Uncontrolled hypertension
• Existing breast and endometrial cancer
• Undiagnosed uterine bleeding
• Elevated triglycerides
• Pregnancy
• Functional heart disease
• Active liver disease
 Relative Contraindications
• Heavy smokers (35 years old)
• Migraines
• Undiagnosed cause of amenorrhea
• Depression
• Prolactin-secreting macroadenomas
 OCPS: Advantages
• Highly effective
• Readily available
• Affordable
• Easy administration
• Many non contraceptive health benefits
OCPS: Non contraceptive health
benefits
• Endometrial cancer-protective
• Ovarian cancer-protective
• Colorectal cancer-protective
OCPS: Non contraceptive health
benefits
• Antiestrogenic effects of progestin
1.reduction of menstrual blood loss and less
risk for iron deficiency anemia
2.less incidence of menorrhagia, irregular
menses and intermenstrual bleeding
3.less likely to develop endometrial adenoCA
4.reduction of incidence of benign breast
diseases
OCPS: Non contraceptive health
benefits
• Inhibition of Ovulation
1.less dysmenorrhea and premenstrual
tension
2.protection against development of
functional ovarian cysts
3.reduction in size of functional ovarian
cyst
4.protection vs ovarian cancer
 OCPS: Non contraceptive health
benefits
• Other Benefits
1.risk reduction rheumatoid arthritis
2.protection vs.PID
3.reduction in incidence of ectopic
pregnancy
4.reduction of bone loss-perimenopause
 Important Points in Prescribing
OCPs
• Adolescent
• After pregnancy
• Nursing mothers
• Cycling women
 OCP Users: Follow-up
• Lab test not necessary for healthy
women
• Nondirected history and BP after 3
months then….
• Annual visits: BP, weight, complete PE,
cytology
Long Acting Hormonal
Contraception
 Four types
• Contraceptive patch
 Four types
• Contraceptive vaginal ring
 Four Types
• Injectables
 Four types
• Subdermal Implants
 Contraceptive Patch
• 75g ethinyl estradiol + 6.0 mg
norelgestromin
• One patch per week for three weeks
followed by 1 week patch free
• MOA similar to OCPs
• Buttocks, upper outer arm, lower
abdomen. Upper torso except breast
 Contraceptive Vaginal Ring
• Steroid delivery through vaginal mucosa
directly into circulation
• 2.7 mg ethinyl estradiol and 11.7 mg
etonorgestrel
• Placed in vagina for 21 days followed by
removal for 7 days then insertion of new ring
• One size, no fitting
• MOA like OCPs
• Expulsion uncommon
 Injectables
• Three formulations

1. DMPA
2. Norethindrone enanthate
3. Estrogen + progestin formulations
 Injectables: DMPA
• IM or subcutaneous preparations
• Very effective reversible method
• 3 MOAs
1. Inhibition of ovulation
2. Thinning of endometrium
3. Cervical mucus changes
• Given within the first 5 days of the cycle
Advantages : DMPA and Implant

• No daily intake of pills

• Infrequent administration
• Maybe appropriate for those with
contraindications to estrogen
 Benefits: DMPA
• Definite risk reduction
PID and salpingitis
endometrial cancer
iron deficiency anemia
sickle cell problems
 Benefits: DMPA
• Ovarian cysts
• Dysmenorrhea
• Endometriosis
• Epileptic seizures
• Vaginal candidiasis
 Disadvantage and Adverse
Effects: Implants
• Unscheduled or irregular uterine
bleeding
• Need for minor surgical procedure to
insert and remove device
• Operative site-potential site for infection
(uncommon)
 Disadvantages and Adverse
effects: DMPA
• Unscheduled or irregular bleeding
• Delayed resumption of ovulation
• Weight gain-unclear
• Depression and mood changes- no
clinical trials for evidence
• Headache- not enough studies
 Disadvantages and Adverse
effects: DMPA
• Metabolic effects-
insignificant effects on lipid*, glucose
and protein metabolism

*lowers HDL but DMPA not demonstrated

to accelerate atherosclerosis.
 Disadvantages and Adverse
effects: DMPA
• Bone loss
suggested in some studies but is
reversible
calcium supplementation
• Neoplastic effects
Does not affect incidence of breast,
cervical and ovarian cancers
Intrauterine Device/ Intrauterine
System
 IUD/IUS
• plastic copper- or progestin-
impregnanted device placed in the
endometrial cavity
• Two types currently available
Copper T 380A IUD (12 years)
LNG IUS (5 years)
 Copper T380A: MOA
• Spermicide (local sterile inflammation)
• Impedance of sperm transport and
viability in the cervical mucus (Copper)
 Levonorgestrel Intrauterine
System (LNG IUS): MOA
• Spermicide
• Progestin effects
 IUD Insertion
• Anyday of the cycle provided the
receiver is NOT PREGNANT
 Advantages of IUD
• Highly effective
• No associated systemic metabolic
effects
• Single act of motivation

The IUD has the highest continuation rate

of all reversible methods
No permanent effects on fertility
 Advantages of IUD
The IUD has the highest continuation rate
of all reversible methods
No permanent effects on fertility
LNG IUS- reduces Menstrual Blood Loss
 Potential Adverse Effects
• Uterine bleeding (Copper T380A)
• Perforation during insertion
• Infection
• Complication relating to pregnancy with
IUD-in-utero
 Pregnancy with IUD-in-Utero
• Congenital anomalies - no increased
risk
• Spontaneous abortion
• Septic abortion
• Ectopic Pregnancy*
• Prematurity
 Pregnancy with IUD-in-Utero

• IUDs effectively reduces all pregnancies

including ectopic ones. Ectopic pregnancy is
reduced by 90% compared to those without
contraception. But if pregnancy does occur
with the IUD in place, the risk of it being
ectopic increases threefold.
 Contraindication to IUD
• Pregnancy or suspected pregnancy
• Acute PID
• Postpartum endometritis or infected
abortion in the last 3 months
• Known or suspected uterine or cervical
CA
 Contraindication to IUD
• Genital bleeding of unknown origin
• Untreated acute cervicitis
• Previously inserted IUD that does not
been removed
Sterilization
 Sterilization
• Permanent contraception
• Fallopian tubes, vas deferens
• Reversal are difficult, success rates
variable
• Pregnancy rates: extent of damage,
surgeon’s expertise
 Vasectomy
• Short outpatient procedure
• Local anesthesia
• Sterility after 14-20 ejaculations
• Two aspermic ejaculates required
 Vasectomy: Complications
• Hematoma
• Sperm granulomas
• Spontaneous reanastomosis
 Vasectomy: Disadvantage
• Difficult and meticulous reversal or
reanastomosis procedures with success
rate only 50%
 Bilateral Tubal Ligation
• More complicated
• Transperitoneal incision
• Often under general anesthesia, but can
be also under local anesthesia
• Postpartum or interval
• Minilaparotomy or laparoscopy
 BTL
• Most effective and least destructive type
of BTL- preferred for young women
(Modified Pomeroy and laparoscopic
band technique)
• Failure rates increase with duration of
time from procedure (esp. bipolar
coagulation and spring clips)
 BTL: Complications
• Bleeding
• Infection
• Anesthetic complications
• Bowel injury (laparoscopic
electrocoagulation)
• Uterine perforation and device
expulsion (microinserts)