• In Conception: there is fusion of the sperm & ovum to produce a new

organism.
• In Contraception: we are preventing this fusion to occur.
• Contraception interferes with:
• Normal process of ovulation
• Hormonal Therapy:
• Oral Contraceptives
• Contraceptive Patches
• Injectable
• Implants
• Vaginal rings
• IUD(with hormone) Intrauterine device
• Implantation
• IUD (copper T)
• Prevents sperm from fertilizing the ovum
• Killing the Sperm (Spermicidals)
• Jells
• Foams
• Ovules
• Interruption by a barrier
• Condoms
• Cervical caps Diaphragms
• Thin films
 Hormonal Therapy:
Oral Contraceptives
Contraceptive Patches
Normal process of Injectable
ovulation Implants
Vaginal rings
IUD(with hormone) Intrauterine device

Contraception
Implantation IUD (copper T)
interferes with:
Killing the Sperm (Spermicidals)
Jells
Foams
Ovules
Prevents sperm from Interruption by a barrier
fertilizing the ovum
Condoms
Cervical caps Diaphragms
Thin films
Types of OC
• According to composition & intent of use
• Combined Pills (COC) Contain estrogens & progestin
• Mini Pills (POP) Contain only a progestin
• Morning-After Pills
Combined Pills (COC)
Mechanism of Action of Combined Pills (COC)
• COC act mainly by preventing ovulation by suppressing the release of
gonadotrophins. Yet, by doing so they also:
• • Inhibit implantation by: ↓ endometrial proliferation → no ovum
can be embedded + ↓ secretion & peristalsis in fallopian tubes →
hinder transport
• • Inhibit fertilization: ↑ viscosity of cervical secretion → no sperm
pass
Route/Dosage
• Monthly Pills
• They were essentially designed to mimic the menstrual cycle by producing a monthly
withdrawal bleeding.
• Formulation Currently, their formulation were more improved to also mimic the natural on
going changes in hormonal profile → PHASE FORMULATIONS.
• 1. Monophasic (fixed amount of estrogen & progestin).
• 2. Multiphasic (fixed amount of estrogen (or variable) + amount of progestin ↑↑ (in 2nd
half or 3 successive phases of cycle)). (Mimic the natural cycle)
Methods of Administration
• • Pills are better taken same time of day.
• • For 21 days; starting on day 5 / ending at day 26.
• • This is followed by a 7 day pill free period.
To Improve Compliance A formulation of 28 pills:
• • The first 21 pills are of multiphasic formulation.
• • Followed by the last 7 pills are actually placebo. (contain sugar)
• indications
• As a contraceptive; In women seeking; a reliable, reversible, coitally-
independent method of contraception.
• Efficacy reach up to (99.9%) in preventing pregnancy if a woman is
compliant.
• • Other indications;
• As a HRT.
• Endometriosis; specially the extended cycle pills
Adverse Effects
• A. Estrogen Relate: • B. Progestin Related:
• 1. Nausea and breast tenderness. • 1. Nausea, vomiting.
• 2. Headache.
• 3. ↑ Skin Pigmentation.
• 2. Headache.
• 4. Impair glucose tolerance. • 3. Fatigue, depression of mood.
• 5. ↑ incidence of breast, vaginal & • 4. Menstrual irregularities.
cervical cancer?
• 5. Weight gain.
• 6. Cardiovascular - major problem
• • Thromboembolism • 6. Hirsutism , masculinization.
• • Hypertension • 7. Ectopic pregnancy.
• 7. ↑ frequency of gall bladder disease.
Contraindications
• Thrombophlebitis / thromboembolic disorders

• CHF or other causes of edema

• Vaginal bleeding of undiagnosed etiology

• Known or suspected pregnancy

• Known or suspected breast cancer, or estrogen-dependent neoplasms

• Impaired hepatic functions

• Fibroid tumors – use mini pill

• Dyslipidemia, diabetes, hypertension, migraine…..

• Lactating mothers – use mini pill

Interactions
A. Medications that cause contraceptive failure: ( i.e. impairing absorption & CYT
P450 Inducers)
• • Antibiotics that interfere with normal GI flora → ↓absorption & ↓
enterohepatic recycling → ↓ its bioavailability.
• • Microsomal Enzyme Inducers → ↑ catabolism of OC. (Phenytoin ,
Phenobarbitone, Rifampin)
B. Medications that ↑ COC toxicity: (i.e. CYT P450 inhibitors)
• • Microsomal Enzyme Inhibitors; ↓ metabolism of OC → ↑ toxicity.
(Acetominophen, Erythromycin, SSRIs.)
C. Medications of altered clearance (↓) by COC: ↑ toxicity
WARFARIN, Cyclosporine, Theophyline.
Progestin-Only Pills (POP)
Contains only a progestin → as norethindrone or desogestrel….
Mechanisms of action
increase cervical mucous plug → no sperm penetration → inhibit fertilization.
Indications
 Are alternative when oestrogen is contraindicated
(specially in cardio-vascular, hepatobiliary, cancer and some metabolic disorders)
 Are used with no age limits, in smokers & during lactation.
Methods of Administration
 Should be taken every day, the same time, better in evenings, all year round.
 Start on first day of menses. Taken daily and continuously
ADRs & Contraindications
• That related to progestins only.
 Morning-After Pills

Emergency Hormonal Contraception

• Inhibit ovulation/fertilization;
• may also alter tubal transport of sperm/egg and
• prevent implantation.
Vaginal Ring, Transdermal Patch:
• Inhibits ovulation,
• decreases sperm entry into uterus,
• decreases likelihood of implantation.
Hormonal contraceptives

 are systemic in nature

 a prostagen combined with estrogen or

 progestagen alone.

 These methods include:-

1. Oral contraceptives.

2. Progestin only injectables.

3. Contraceptive implants

Oral contraceptives

• Are pills that taken by mouth to prevent pregnancy.

estrogen and progestin (combined oral contraceptives (COCs))

progestin only (progestin-only pills (POPs).

 Combined Oral Contraceptives (COCs)

 preparations of synthetic estrogen and progestrone

 highly effective in preventing pregnancy.

Monophasic: All 21 active pills contain the same amount of estrogen and progestin dose

Biphasic: The 21 active pills contain 2 different estrogen and progestin dose combination

Multiphase: The 21 active pills contain 3 different estrogen and progestin dose combination

 Monophasic: These pills (28 pill cycle) are commonly used and preferred in our country.

 Examples of available pills include Micrgynon and Lofemomenol.

Indications

As a contraceptive; In women seeking; a reliable, reversible, coitally-independent

method of contraception.

Efficacy reach up to (99.9%) in preventing pregnancy if a woman is compliant.

 Combined Pills (COC)
Mechanism of Action

Preventing ovulation by suppressing the release of gonadotrophins.

Inhibit implantation by: ↓ endometrial proliferation → no ovum can be embedded +

↓ secretion & peristalsis in fallopian tubes → hinder transport

Inhibit fertilization: ↑ viscosity of cervical secretion → no sperm pass

COCs are available in packets of:

• a) 21 pills, where a pill is taken for 21 days and

a break from pill-taking occurs for 7 days before starting a new packet

• b) 28 pills, where a hormonal pill is taken every day for 21 days and

 the break occurs when seven placebo pills are taken as the last pills in each packet.
Route/Dosage

• Monthly Pills

• They designed to mimic the menstrual cycle by producing a monthly withdrawal bleeding.

• Their formulation were also mimic the natural on going changes in hormonal profile

• 1. Monophasic: fixed amount of estrogen & progestin.

• 2. Multiphasic: fixed amount of estrogen or variable + amount of progestin ↑↑ in 2nd half

or 3 successive phases of cycle. Mimic the natural cycle.

Methods of Administration

• Pills are better taken same time of day.

• For 21 days; starting on day 5 / ending at day 26.

• This is followed by a 7 day pill free period.

• To Improve Compliance A formulation of 28 pills:

The first 21 pills are of multiphasic formulation.

Followed by the last 7 pills are actually placebo. (contain sugar)

Mechanism of Action

 Suppress ovulation

 Thicken cervical mucus, preventing sperm penetration

 Make the endometrium less favorable for implantation

 Reduce sperm transport in upper genital tract (fallopian tubes)

Advantages

 Contraceptive

Highly effective when taken correctly and consistently

• (0.1 pregnancies per 100 women during the first year of use)

Effective immediately (after 24 hours)

Do not interfere with intercourse

Client can stop use any time they want to get pregnant
Noncontraceptive

Decreased menstrual flow and may improve iron deficiency anemia

Decreased menstrual cramps

May lead to more regular menstrual cycles

Protects against ovarian and endometrial cancer

Decreases benign breast disease and ovarian cysts

Prevents ectopic pregnancy

Protects against some causes of PID

Disadvantages

User-dependent (require continued motivation and daily use)

Forgetfulness increases failure

Resupply must be available

Does not protect against GTIs or other STDs (e.g., HBV, HIV/AIDS)
Contra-indications

Pregnancy (known or suspected)

Breast-feeding and fewer than 6-8 weeks postpartum

Unexplained vaginal bleeding (until evaluated)

Active liver disease (viral hepatitis) and Breast cancer

Age 35 and smoker

History of blood clotting problems, heart disease, stroke or high BP (>180/110)

Migraines and focal neurological symptoms or diabetes > 20 years.

Taking drugs like rifampin ,phenytoin and barbiturates

Adverse Effects

• A. Estrogen Relate:

1. Nausea and breast tenderness.

2. Headache.

3. ↑ Skin Pigmentation.

4. Impair glucose tolerance.

5. ↑ incidence of breast, vaginal & cervical cancer?

6. Cardiovascular - major problem (Thromboembolism and Hypertension)

7. ↑ frequency of gall bladder disease.

• B. Progestin Related:

1. Nausea, vomiting.

2. Headache.

3. Fatigue, depression of mood.

4. Menstrual irregularities.

5. Weight gain.

6. Hirsutism , masculinization.

7. Ectopic pregnancy.

 Interactions
A. Medications that cause contraceptive failure:
Antibiotics that interfere with normal GI flora → ↓absorption & ↓ enterohepatic
recycling → ↓ its bioavailability.
Microsomal Enzyme Inducers → ↑ catabolism of OC.

• (Phenytoin , Phenobarbitone, Rifampin)

B. Medications that ↑ COC toxicity: (CYT P450 inhibitors)

• Microsomal Enzyme Inhibitors; ↓ metabolism of OC → ↑ toxicity.

• (Acetominophen, Erythromycin, SSRIs.)

C. Medications of altered clearance (↓) by COC: ↑ toxicity (warfarin, Cyclosporine, Theophyline.)

Client Instructions

Take 1 pill each day, preferably at the same time of day.

If vomit within 30 minutes of taking a pill, take another pill or use a backup method if

have sex during the next 7 days.

If forget to take a pill, take it as soon as you remember

If forget to take 2 or more pills, take 2 pills every day until back on schedule.

 Use a backup method (e.g., condoms) or else do not have sex for 7 days.

If miss 2 or more menstrual periods, check to see if you are pregnant.
 Progestin Only Pills (POPs)

• the pill only contains progestin, no estrogen as norethindrone or desogestrel….

• These pills may be used during the breast-feeding period, they do not reduce milk flow.

Indications

• Are alternative when oestrogen is contraindicated

 (specially in cardio-vascular, hepatobiliary, cancer and some metabolic disorders)

• Are used with no age limits, in smokers & during lactation.

Mechanism of action

Thickens cervical mucus, preventing sperm penetration→ inhibit fertilization

Suppresses ovulation

Makes the endometrium less favorable for implantation

Reduces sperm transport in upper genital tract (fallopian tubes)

Methods of Administration

• Should be taken every day, the same time, better in evenings, all year round.

• Start on first day of menses. Taken daily and continuously

ADRs & Contraindications

• That related to progestins only.

Advantages

• Contraceptive

Effective when taken at the same time every day

 (0.5-10 pregnancies per 100 women during the first year of use)

Immediately effective (<24 hours)

Does not interfere with intercourse

Does not affect breast-feeding

Immediate return of fertility when stopped

No estrogenic side effect

Noncontraceptive

May decrease menstrual cramps

May decrease menstrual bleeding and may improve iron deficiency anemia

Protects against endometrial cancer

Decreases benign breast disease

Protects against some causes of PID

Disadvantages

User-dependent (require continues motivation and daily use)

Must be taken at the same time every day

Forgetfulness increases failure

Resupply must be available

Do not protect against GTIs or other STDs (e.g., HBV, HIV/AIDS)
Contra-indications

Pregnancy (known or suspected)

Known or suspected cancer of the reproductive tract and breast

Undiagnosed genital tract bleeding

Taking drugs like rifampin ,phenytoin, and barbiturates

ADRs

1. Nausea, vomiting.

2. Headache.

3. Fatigue, depression of mood.

4. Menstrual irregularities.

5. Weight gain.

6. Hirsutism , masculinization.

7. Ectopic pregnancy.

Client Instructions

Take 1 pill at the same time each day.

Take the first pill on the first day of your menstrual period.

Take all the pills in the pack. Start a new pack on the day after you take the last pill.

If vomit within 30 minutes of taking a pill,

• take another pill or use a backup method if sex during the next 48 hours.

If you take a pill more than 3 hours late, take it as soon as you remember.

• Use a backup method if you have sex during the next 48 hours.

If forget to take one or more pills, take the next pill when you remember.

• Use a backup method if you have sex during the next 48 hours.
Injectable contraceptives

 Systemic progestin preparations administered by intramuscular injection.

 The most common is Depo-Provera/DMPA, which given every 3 months.

 A second PIC is Noristerat, which is given every 2 months.

Mechanism of action

Thickens cervical mucus, preventing sperm penetration

Make the endometrium less favorable for implantation

Reduces sperm transport in fallopian tubes and Suppresses ovulation

• Mechanism of action
• • Thickens cervical mucus, preventing sperm penetration
• • Make the endometrium less favorable for implantation
• • Reduces sperm transport in upper genital tract (fallopian tubes)
• • Suppresses ovulation (release of eggs from ovaries)
Advantages
• Contraceptive

Highly effective

Rapidly effective (<24 hours)

Intermediate-term method (2 or 3 months per injection

Does not interfere with intercourse

Does not affect breast-feeding

No estrogenic side effects

No daily pill taking, long term pregnancy prevention but reversible
Noncontraceptive

May decrease menstrual cramps

May decrease menstrual bleeding and may improve iron deficiency anemia

Protects against endometrial and ovarian cancer

Decreases benign breast disease

Decreases ectopic pregnancy and Protects against some causes of PID

Helps prevent Uterine fibroids

• Disadvantages

Heavy bleeding can occur initially but is rare.

Amenorrhea after first year of use is normal.

User-dependent (must return for injection every 2 or 3 months)

Delay in return of fertility (DMPA only)

Excessive vaginal bleeding in rare instances

Do not protect against GTIs or other STDs (e.g., HBV, HIV/AIDS)

My cause headaches, breast tenderness, moodiness, nausea, hair loss, less sexual
drive or acne in some women.
 Contraceptive implants
The implant system consists of a set of 6 small, plastic capsules.

Each capsule is about the size of a small matchstick.

The capsules are placed under the skin of a woman’s upper arm.

Norplant capsules contain a progestin (called levonorgestrol), similar to a natural hormone

It is released very slowly from all 6 capsules.

Thus the capsules supply a steady, very low dose of progestin.

Norplant contains no estrogen.

A set of Norplant capsules can prevent pregnancy for at least 5 years

Mechanisms of Action

• Thickens cervical mucus, preventing sperm penetration

• Make the endometrium less favorable for implantation

• Reduces sperm transport in upper genital tract (fallopian tubes)

• Suppress ovulation
Advantages

• Contracepitve

Highly effective (0.2-1 pregnancies per 100 women during the first year of use)

Rapidly effective (<24 hours)

Long-term method (up to 5 years protection)

Does not interfere with intercourse

Does not affect breast-feeding

Immediate return of fertility on removal

Contains no estrogen no side effects of estrogen

• Noncontraceptive
• • May decrease menstrual cramps
• • May decrease menstrual bleeding and may improve iron deficiency
anemia
• • Protects against endometrial cancer
• • Decreases benign breast disease
• • Decreases ectopic pregnancy
• • Protects against some causes of PID
Disadvantages

Irregular bleeding/spotting initially in most women

Some weight gain or loss may occur

Amenorrhoea

Effectiveness lowered when certain drugs like rifampin ,phenytoin and barbiturates

Does not protect against GTIs or other STDs (e.g., HBV, HIV/AIDS)
 Barrier methods
• Used for prevention of pregnancy as well as certain sexually transmitted diseases.
• Prevent the ascent of the spermatozoa into the upper female genital tract.
 Emergency Contraceptives
• used to prevent pregnancy after unprotected intercourse

• Emergency contraceptives not be used in place of family planning methods

• used only in an emergency, for example

- In cases of rape

- A condom has broken

- An IUCD has come out of place

- Pills are lost or forgotten

- Sex took place without contraception and the woman wants to avoid pregnancy.