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CONTRACEPTION FOR

THE 21 CENTURY
ST
Development in contraception
 Not at pace of tech dev:
 Dev however note worthy and
attitude in developing countries
changing
 Slow pace

Extensive research and rigorous


clinical trials
Govt approval
Cost benefit to company and
concumers
New contraceptives

 Modifications of old one :


No need to change winning team
Cost
Medicolegal issues
Clinical trials shorter
New innovations for the 21st
century
 Not all covered
 Focuses on innovations that are
more effective,
 easier to deliver
 Fewer side effects than
available methods
 New info on existing ones
Methods

 Physical
 Behavioral
 Medical
 Surgical
VAGINAL RINGS
 Two types : combined and po
 Combined estrogens and
progestin rings
Good cycle control, steady
delivery of hormones > OC
Under a woman's control:
insertion and removal; any
where in vagina that is most
comfortable/ upper vagina
RINGS

 Continuous use: all day/ all night


 Difuses into vagina- into blood
 Can be removed up to 3 hrs for
comfort for cleaning and sex
TWO COMBINED VAGINA
RINGS
 NuvaRing ( organon)
 Available in brazil, chile

Release 120ug of etonogestrel


and 15ug of EE/ day
Use for 3 wks. Rest for 1 wk-
withdrawal bleeding
U may skip this’
Use new one per month
RING: CLINICAL TRIAL

 Realeases 150ug of nestorolone


and 15ug of EE/day
For developing countries: use for
1 year
Use for 3 rest for 1 and reuse
effectiveness
1.2 preg per 100 women in 1st
year of use
Side effects

 Abnormal bleeding < COC


 s/e of COC but less
TWO PROGESTIN- ONLY
RINGS
 PROGERING:
PROGESTERONE
 UNNAMED RING: Synthetic
progestin ; nestorone
 Effects on cervix , endometrium,
ovulation
 Less effective than combined ,
best in B/F( decrease fert).
Progesterone rings

 Best in lactating women


 Releases 10mg of
progesterone/day-
 Lasts for 1 year

 S/E

Infection, bleeding problems


Nestorone rings

 Contains nestorone{ ST1435),


 Releases 50-100ug /day
 Best in lactation, no passage in
breast milk
 Not in market
Rings

 Acceptability : easy, to insert,


use and remove
 Non acceptability: too much
responsibility on woman
Transdermal contraception
 Patch; combined prep
 Sprays, gels: progestin

 Combined patches
Ortho Evra( ortho—McNeil)
Releases 150ug of norelgestromin and
20ug of EE.
Patch change wkly for 3wks, 1wk free
Design

 Square patch-4.45cm , diff.


colors
 3 layers; outer protective
polyester layer, middle
medicated adhesive layer and a
clear polyester- removable
 Delivers hormones thru skin
 Placed on any part of body
Design
 Adheres to skin: normal activity
even bathing
 Reduce adhesion: creams, oils
powder, makeup.
 As effective as COC. Better
compliance
 Experimental patch: 3.16 cm
release 50ug gestodene and
18ug of EE/day.
Correct use

 Within 5 days of menses


 Change every wk with a new
one for 3 wks in a new location
 4th wk: no ; for withdrawal
bleeding
 Studies on for continous use
 Good compliance
Effectiveness

 0.6 of every 100 women get


preg
 < with wt > 90kg same for COC.

INCREASE METABOLISM/ FAT


STORAGE

S/E: skin irritation/rash. Effects of


COC but much less.
SPRAY ON
CONTRACEPTIVES
 RESEACH: PROGESTIN
( nestorolone); spray and gel
 Given daily: dries fast and
immediately absorbed:
suppresses ovulation
CONTRACEPTIVE
IMPLANTS
 Decrease nos of rods and
capsules
 Change of progestins

 Minimise S/E esp bleeding

 Safety in B/F

NORPLANT : 6 CAPS
S/E bleeding
Newer implants

 1 to 2 rods or caps
 Rods> casules
 Rods: filled with steroid crystals
and polymer
 Capsules: hollow polymer tubes
filled with free steroid crystals
New implants

 Jadelle and implanon.


Nestorolone is not in market
 Expensive to develop
 Require training to insert
new implant system

 Few caps or rods: insertion/


removal easier
 Few compl./ less discomfort
 Newer implants : specially
designed applicator, no need for
separate incision
 Insertion less than 5 mins
New formulation with fewer
rods
 Jadelle and chinese nos 2 :
levonorgestrel
 Implanon: etonogestrel

 Elcometrine and nestorolone:


ST1235
Cervix, endometrium, ovulation
Levonogestrel implants

Jadelle and chinese nos 2 : 2


rods
Delivers same dose of
levonorgesterel but at higher
rate 140mg
Easier to insert and remove
Chinese nos 2 : sinoplant : 150mg
levonorgestrel
Etonogestrel implants

 Implanon: single rod; 3 yrs


 Complete suppression of
ovulation> norplant
Nestorone implants
 ST 1435: under dev. Effect for 2 yrs
 Single rod made of silicone
membrane
 Useful in B/f women. None in breast
milk
 Less irregular bleeding
 S/E
 Bleeding disorder as for all
progestins: low preg
COMBINED INJECTABLES

 PROGESTINS AND
ESTROGENS
 MONTHLY INJ.
 Better cycle control and
 Early return of fertility
Examples

 Cyclofem, cycloprovera,
mesigyna
 Dev on for some time
 Not widely available
Effectiveness
 Inhibits ovulation, acts on cervix and
endometrium
 0.1 to 0.4 preg for every 100 women

 Quick return of fertility: 6 wks

 S/E

Side effects of COC.


Lack of access
Better in S/E esp bleeding
PROGESTINS
INNOVATION

 NEW DMPA FORMULATION


 DMPA-SC- subcut inj ( uniject) :
self administered: newly
approved
 Slower and sustained
absorbtion: contains 104 mg of
DMPA
NEW

 CYCLOFEM/
CYCLOPROVERA.
FEMINENA/LUNELLE/LUNELL
A: 25mg MPA + 5mg estradiol
cypionate
 MESIGYNA/NORIGYNON:
50mg norethisterone
enanthate+ 5mg estradiol
valerate
CONDOMS

 MALE / FEMALE: non latex and


latex
 Protects against HIV

MALE CONDOMS
Synthetic nonlatex: polyurethrane,
styrene ethylene butylene
styrene (SEBS) sold as tactylon
Non latex condoms

 Poyurethrane and SEBS


Longer shelf life
Can be used with oil based
lubricants
Less odor, more comfortable, less
constricting
Transfer heat and sensation
better
Use

 Poly urethrane: in use since


1995
 SEBS : not marketed

 Widely popular despite

More breakage, slippage


FEMALE CONDOMS

 ONLY available is FC Female


condom( formerly Reality):
polyurethrane: costly
 Newer ones- the FC2, the VA
feminine, PATH womens
condom condom- latex rubber :
less cost
Fertility awareness method

Two new variations


The standard days method
Two day method
Uses
Couple do want clinical methods,
or lack of access
Conditions

 Involvement of both partners


 Communicate about sex
 Women empowerment
The standard days method
 Identification of fertile and
infertile phase of cycle
 Use of color coded beads :
cycleBeads repesenting cycle.
Moves a rubber ring to the next
bead every day. When on white:
fertile phase
 Fertile window: several days B4
and few hrs after ovulation
Timing
 Computer simulation: variation
in individual cycle and in various
women
 Fertile period: days 8 and 19 0f
cycle
 #CYCLE HAVE TO BE BE 26
TO 32 DAYS.
 Effectiveness
 Like barrier: 5 to 12 preg/hwy
Two day method

 Any cycle length irrespective of


regularity
 Avoid intercourse for 10—15
days per cycle
Method

 Fertile : cervical mucus


yesterday and today
 Infertile : no cervical mucus for
two consecutive days
 Better and less cumbersome
than
Billings and symptothermal
Effectiveness

 Like barrier
ORAL CONTRACEPTIVES

Basis of new one


Decrease S/E and increase
effectiveness
NEW ONES
Continous use COC
COC with new prgestin
New POP
CONTINOUS- USE ORAL
CONTRACEPTIVES
 WHY NOT. ? USE OF PILL BREAK
 Break : mimic natural cycle

 CONTINOUS USE:

Reduce nos of bleeding days/ year


Reduce S/E of hormone break:
haedache, migraines,
premenstrualsyndrome,mood swings
PROBLEMS

 Breakthrough bleed. Decrease


with long use
 Seasonale : in use now.cont.
use; contains 150ug
levonorgestrel and 30u of EE:
use for 84 days( 12 wks) with 7
day break
Drospirenone COC

 Yasmin : 3mg drospirelone and


30ug EE
 Advantages

Reduce acne and excess hair


growth
Less water retention and wt gain
S/E same as for COC
Desogestrel POP

 CERAZETTE: 75ug desogestrel


 Primarily inhibits ovulation
 Can be 12 hrs late for taking it
 0.2 preg/ hwy
INTRAUTERINE DEVICES

 NEW
Insertion and removal easier
Reduce expulsion , pain and
bleeding
Examples
IUS- PROG containing
Frameless IUD (GyneFix)
Progestin releasing IUS

 MIRENA: levonorgestrel;
20ug/day: use for 5 yrs
 As effective as sterilisation

 Preg: 0.1 –0.2 per 100 women


in 1 year. In 5yrs : 0.5—1.1
 S/E

Minimal and similar to others but


better than other iud
Frameless IUD

 GyneFix
 NO PLASTIC T SHAPE FRAME
 Several copper cylinders tied
together on a string
 Anchored 1cm deep into fundus
 Cause less pain and bleeding
GyneFix
 DECREASE BLEEDING
 INCR. EXPULSION
 DIFF INSERTION TECHNIQUE
 HIGH SKILL

OTHERS
FibroPlant-LNG
FRAMELESS
Contains LNG
TRANSCERVICAL FEMALE
STERILIZATION
 Safer and easier
 Chemicals : quinacrine
 Plugs: Adriana method
 Microcols: essure
 Old methods: minilap, lap.;
skilled persons, sterile condition
 Newer methods : increase
access: no surgery
ESSURE-MICROCOIL
 Spring like device inserted via
hysteroscope via cervix into tubes
 Scar tissue form over it in 3 months
 Local anaesthesia< 1 hour
 90% success

 3months: x-ray or USS to check


placement of microcoil
Effectiveness

 Like BTL
 Not reversible
 Back up contraception till 3
months
 Expensive
Quinacrine- a chemical
compound
 Pellets inserted into uterus-
tubal scarring
 No physician needed

 Safety test ongoing

 Less effective than BTL

1 to 2 preg/hwy. more in 5 years


Adiana procedure

 Via hysteroscope insert


catheter: deliver low level
radiofrequency- superficial
lesion then insert a plastic
implant called matrix into lesion
 In 3 months scar tissue
 Expensive also for dev.
countries
Male hormonal contraception

 Ongoing clinical trials


 Uses testosterone with or
without progestins to suppress
spermatogenesis
 Formulations : pills patches,inj,
implants
 Others : reversible vas
occlusion
Testosterone – only
formulations
 International reseach
 Wkly inj. Of 200mg testosterone
enanthate
 Chinese study advanced:
testosterone undecanoate inj. Is
monthly
 Combined therapy better in
nonasians
Combined formulations

 Progestins> GnRh analogue:


speeds and improves
suppression of sperm
production- less testosterone
 S/E

NO EFFECT ON MALE SEX


DRIVE OR AGGRESSION
Wt gain, dec.HDL
EFFECTIVENESS

 < 1 million sperms per ml of


ejaculate- 1.4 preg per year
among partners of 100 men
 Acceptability is high
New long term male
contraception in clinical trials
 RISUG and the Intra Vas device
 RISUG: Injected Gel blocks
sperm
 Revesible inhibition of sperm
under Guidance: is a clear gel
made of styrene maleic
anhydride(SMA) mixed with
dimethyl sulfoxide (DMSO)
TECHNIQUE

 Inj. Into vas deferens: blocks


flow
 Reversible: flushed out with
DMSO or NaHco3 or via
massage, vibration or low level
electrical current
Intravas device: Two
implanted plugs block sperm
 Nonsurgical
 reversible
Gene based approaches

 Contraceptives target genes


controlling sperm and egg
production or the proteins
controlling fusion of egg and
sperm
 Decade away from realisation
 S/e minimal