Contraception

Anne Karyll T. Tungcul, MD

1st Year Resident

Ospital ng Makati
 ACOG recognizes these tiers, recommends
counseling on al options, and encourages
highly effective LARC for appropriate
candidates.

 Implants and intrauterine devices are

found in the top tier
 INTRAUTERINE DEVICES
 chemically active and continually elute either copper or levonorgestrel

 T-shaped frame of polyethylene that is compounded with barium to render them radiopaque

 5 IUDs currently approved: Mirena, Kyleena, Liletta, Skyla, T380A (Paragard)

  prevention of fertilization
INTRAUTER
INE  LNG-IUS, long-term progestin release
leads to endometrial atrophy, which
DEVICES hinders normal implantation and
create scant viscous cervical mucus
that obstructs sperm motility

 intense local endometrial

Contraceptive inflammatory response is induced →
cellular and humoral components are
Action expressed in endometrial tissue and
in fluid filling the uterine cavity and
fallopian tubes → decreased sperm
and egg viability
INTRAUTER
INE
DEVICES
1. Ectopic Pregnancy
2. Lost Device
3. Perforation
4. Menstrual Changes
Method- Specific 5. Infection
Adverse Effects 6. Pregnancy with an IUD
INTRAUTER  complete uterine involution - at least
6 weeks after delivery
INE
DEVICES  Alternatively, immediately after
miscarriage, surgical abortion, or
delivery, in the absence of overt
infection

 insertion near the end of normal

IUD Insertion menstruation, when the cervix is
usually softer and somewhat more
dilated, may be easier and also
helps exclude early pregnancy
PROGESTIN  thin, pliable progestin containing
cylinders
IMPLANTS  implanted subdermally and release
hormone over many years

 Nexplanon is a single-rod implant

with 68 mg of etonogestrel covered
by an ethylene vinyl acetate
copolymer cover.
Etonogestrel lmplant
 Implanon - not radiopaque
 Both implants are similarly shaped
and pharmacologically identical.
PROGESTIN
IMPLANTS
 first progestin implants contained
levonorgestrel (LNG)
 placed subdermally on the inner
arm approximately 8 cm from the
elbow and have similar removal
Levonorgestrel lmplants steps with etonogestrel implant
PROGESTIN
IMPLANTS  Unscheduled bleeding

 Device-specific adverse effects

derive mainly from malpositioning

 branches of the medial antebrachial

cutaneous nerve can be injured
Method-Specific during implant or needle insertion
that is too deep or during
Adverse Effects exploration for a lost implant

 numbness and paresthesia over the

anteromedial aspect of the forearm
PROGESTIN
IMPLANTS  For those not currently using
hormonal contraception, the
etonogestrel implant is ideally
inserted within 5 days of menses
onset

Implant Insertion  With LNG-releasing implants,

contraception is established within
24 hours if inserted within the first 7
days of the menstrual cycle
PROGESTIN 
1.
For transitioning methods:
on the day of the first placebo
IMPLANTS combination oral contraceptive
(COC) pill
2. on the day that the next depot-
medroxyprogesterone injection
would be due
3. within 24 hours of taking the last
POP
Implant Insertion
PROGESTIN
IMPLANTS
 In women certain that they are not
pregnant, insertion at other times of
the cycle is followed by alternative
contraception for 7 days.

Implant Insertion  Related to pregnancy, an implant

may be inserted before discharge
following delivery or abortion.
Nexplanon Insertion Technique
PROGESTIN-  implants injectables, and pills

ONLY  primary contraceptive action:

CONTRACEPTI suppress luteinizing hormone (LH)
and in turn block ovulation
VES  other effects: cervical mucus is
thickened to retard sperm passage,
and atrophy renders the
Actions and Side endometrium unfavorable for
Effects implantation

 irregular or heavy uterine bleeding

is a distinct disadvantage
PROGESTIN-
ONLY
CONTRACEPTI
VES .
 irregular or heavy uterine bleeding

 with prolonged use, progestins

Actions and Side induce endometrial atrophy, which
leads to sustained amenorrhea
Effects
 do not impair milk production
PROGESTIN-
ONLY
CONTRACEPTI
VES
Two absolute contraindications:
 breast cancer
 pregnancy
Contraindications
HORMONAL
CONTRACEPTI
VES 1. Combination Hormonal
Contraceptives
2. Combination Oral Contraceptive
Pills
3. Transdermal Patch
4. Transvaginal Ring
5. Injectable Progestin Contraceptives
6. Progestin-Only Pills
HORMONAL
CONTRACEPTI
VES  suppression of hypothalamic
gonadotropin-releasing factors

 blocks pituitary secretion of follicle-

stimulating hormone (FSH) and
Combination Hormonal luteinizing hormone (LH)
Contraceptives
Mechanism of Action  inhibits ovulation
HORMONAL  Progestin component: provides
ovulation prevention by suppressing
CONTRACEPTI LH; it thickens cervical mucus and
VES thereby retards sperm passage; and
it renders the endometrium
unfavorable for implantation

 Estrogen: blocks ovulation by

suppressing FSH release; stabilizes
Combination Hormonal the endometrium, which prevents
Contraceptives intermenstrual bleeding-also known
as breakthrough bleeding
Mechanism of Action
HORMONAL  Administration: taken daily for a
specified time (2 1 to 81 days) and
CONTRACEPTI then replaced by placebo for a
VES specified time (4 to 7 days), which is
called the "pill-free interval.“

 During these pill-free days,

withdrawal bleeding is expected.

Combination Oral  For general initiation, women ideally

Contraceptive Pills begin COCs on the first day of a
menstrual cycle

 For maximum efficiency, pills are

best taken at the same time each
day.
HORMONAL  Ortho Evra patch contains ethinyl
estradiol and the progestin
CONTRACEPTI norelgestromin
VES  It has an inner layer containing an
adhesive and hormone matrix, and a
water-resistant outer layer
 applied to buttocks, upper outer arm,
lower abdomen, or upper torso, but
the breasts are avoided
Transdermal Patch
HORMONAL
CONTRACEPTI  Initiation of the patch is the same as
VES for COCs

 a new patch is applied weekly for 3

weeks, followed by a patch-free
week to allow withdrawal bleeding

Transdermal Patch  ideally worn no longer than 7 days,

hormone levels remain in an
effective range for up to 9 days. This
affords a 2-day window for patch-
change delays
HORMONAL  flexible intravaginal ring

CONTRACEPTI  ring is constructed of ethinyl vinyl

VES acetate

 measures 54 mm in diameter and 4

mm in cross section

 placed within 5 days of menses

Transvaginal Ring onset and, after 3 weeks of use, is
removed for 1 week to allow
(NuvaRing) withdrawal bleeding

 Contraception will still be afforded if

a ring is left in place for a fourth
week
HORMONAL
CONTRACEPTI
VES
 intramuscular depot
medroxyprogesterone acetate-Depo
Provera (DMPA)-150 mg every 3
Injectable Progestin months
 norethisterone enanthate, 200 mg
Contraceptives every 2 months
HORMONAL  ovulation inhibition, greater cervical
mucus viscosity, and creation of an
CONTRACEPTI endometrium unfavorable for ovum
VES implantation.

 Initial injection is given within the first

5 days following menses onset.
Serum levels sufficient for
contraception are observed by 24
Injectable Progestin hours. Thus, no additional
Contraceptives contraceptive method is required for
initiation within this window.
HORMONAL  So-called mini-pills are progestin-
only contraceptives that are taken
CONTRACEPTI daily
VES  effectiveness depends more on
cervical mucus thickening and
endometrial atrophy

 contraindicated in women with

Progestin-Only Pills known breast cancer or pregnancy
Barrier Methods
 Mechanism of Action: Condoms work
by forming a physical barrier that
keeps sperm out of the vagina.

 Aside from protection against

unplanned pregnancy, their use may
also provide variable protection
Male and Female against sexually transmitted
infections.
Condom
  The couple should abstain from
Fertility vaginal intercourse from menstrual
days 8 - 19 among women with
Awareness-Based cycles of 26 – 32 days.
Method (FAB)  Couples using this method are
advised that the woman is
considered fertile day 8 through 19
of her cycle.
STANDARD DAYS
METHOD  Using a color coded “cycle beads” to
mark the fertile and infertile days of
menstrual cycle, the couple should
abstain from vaginal intercourse on
days 8 – 19 to prevent pregnancy.
Fertility
Awareness-Based
Method (FAB)  relies on a sustained O.4°F rise in
the basal body temperature, which
usually precedes ovulation.
 For maximum efficacy, the woman
Temperature Rhythm must abstain from intercourse from
Method the first day of menses through the
third day after the temperature
increase.
Fertility  Two-Day Method or Billings Method
Awareness-Based  relies on awareness of vaginal
"dryness" and "wetness.“
Method (FAB)  These reflect changes in the
amount and quality of cervical
mucus at different times in the
menstrual cycle.
Cervical Mucus Method  With the Billings Method,
abstinence is required from the
beginning of menses until 4 days
after slippery mucus is identified.
 With the Two-Day Method,
intercourse is considered safe if a
woman did not note mucus on the
day of planned intercourse or the
day prior.
Fertility
Awareness-Based
Method (FAB)
 combines changes in cervical
mucus-onset of fertile period;
changes in basal body temperature-
Symptothermal Method end of fertile period; and calculations
to estimate the time of ovulation
  levonorgestrel is taken as a
EMERGENCY single, onetime 1.5-mg dose,
begins ideally within 72 hours of
CONTRACEPTI unprotected coitus but may be
ON given up to 120 hours

 ulipristal acetate (Ela), taken as a

single 30-mg tablet up to 120
hours after unprotected intercourse
Hormonal Emergency
Contraception  Yuzpe method, provides a
minimum of 100 ug of ethinyl
estradiol and 0.5 mg of
levonorgestrel in each of two
doses. First dose is taken ideally
within 72 hours of intercourse but
may be given up to 1 20 hours.
The initial dose is followed 12
hours later by a second equivalent
dose.
  For women who are candidates,
EMERGENCY Cu-IUD insertion is the most
effective emergency contraceptive
CONTRACEPTI method and provides an effective
ON 10-year method of contraception

 If an IUD is placed up to 5 days

after unprotected coitus, the failure
rate approximates only 0.1 %
Copper-Containing
Intrauterine Devices
 Sterilization
 This requires one time surgery on either partner’s reproductive tract that would prevent the union of the sperm and the egg every time
coitus takes place.

 This type of method should ideally be considered for patients with completed family size.
  Female sterilization; commonly
Sterilization know as Bilateral Tubal Ligation
(BTL), usually achieved by
transecting each fallopian tube
along its length.
 It is recommended that for
sterilization procedures, the
spouses should both give their
consent for the sake of conjugal
TUBAL LIGATION harmony.
  Male sterilization
Sterilization  It involves the occlusion of the
lumen of the vas deferens on each
side
 The client should wait 3 months
before relying on his vasectomy for
contraception, during which he and
his partner may use other forms of
contraceptives. Semen analysis
VASECTOMY can confirm contraceptive
effectiveness after the 3 month
waiting period.
 The client should be informed that
even though considered a
permanent method, vasectomy has
an associated failure rate and that
pregnancies can occur several
years later
 Sterilization
 VASECTOMY

 Male sterilization

 It involves the occlusion of the lumen of the vas deferens on each side

 The client should wait 3 months before relying on his vasectomy for contraception, during which he and his partner may use
other forms of contraceptives. Semen analysis can confirm contraceptive effectiveness after the 3 month waiting period.

 The client should be informed that even though considered a permanent method, vasectomy has an associated failure rate and
that pregnancies can occur several years later