Contraception

Combined hormonal contraception

Progestogen-only preparations
Hormonal emergency contraception
Contraceptive implant
Intrauterine contraception
Barrier methods
Gynaecology by Ten Teachers 19th edition
Sterilization ‹#›
 COCP

Depo-provera

POP (Noriday)

NET-
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COCP (Oralcon) EN
 COCP

NET-
EN
POP (Noriday)

COCP (Oralcon) Depo-provera ‹#›

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 COMBINED ORAL
CONTRACEPTIVE PILLS
(COCP)
 Combined oestrogen progestogen
methods
• Two types of hormones :
Oestrogen (ethinylestradiol) & Progesterone
(Norethindrone, Levonorgestrel, Desogestrel)
 Mode of Action
(act centrally and peripherally)
Inhibition of ovulation.
Oestrogen and progestogen suppress FSH and
LH, preventing follicular development.

Peripheral effects such as endometrium

atrophic and alter the cervical mucus to
prevent sperm ascending into uterine cavity.
 When to start?
• Menses : within 5 days. If more than 5 days,
additional protection for the next 7 days.
• Amenorrhoea : start anytime if certain not
pregnant, additional protection for the next 7
days.
• Post partum (non breastfeeding) :
amenorrhoeic for 21 days or more, can start
immediately if certain not pregnant, but
additional protection for the next 7 days. If
menstrual cycles have returned, can start COC
as usual.

MANAGEMENT OF MISSED
PILLS
 SIDE EFFECTS
– Venous thromboembolism (VTE) - 3-5 fold ↑
– ↑ risk of arterial disease (myocardial infarction,
thromboembolic stroke) among high risk groups
(cigarette smoking and high blood pressure)
– Slight ↑ in risk of developing breast cancer
– Nausea and vomiting
– Weight gain
 Combined hormonal patches
• Transdermal patch containing oestrogen and
progestogen.
• Release norelgestromin 150mg and
ethinylestradiol 20mg per 24 hours.
• Apply weekly for 3 weeks, after which there is
a patch-free week.
• Same risk and benefits as COCP, but more
expensive and better compliance.
 Combined hormonal vaginal rings
• Made of latex free plastic and has diameter of
54mm.
• Release a daily dose of ethinyl estradiol. Worn
for 21 days and removed for 7 days.
• More expensive, insertion and removal of the
ring is easy and it does not need to fit in any
special place in vagina.
 Progestogen-only contraception
• Progestogen-only pill
• Subdermal implant
• Injectables (Depo-provera)
• Hormone releasing intrauterine system
 MODE OF ACTION
• Local effect on cervical mucus
– Making it hostile to ascending sperm
– Preventing sperm transport

• Local effect on endometrium

– Making it thin and atrophic
– Preventing implantation
 PROGESTOGEN-ONLY PILL
• WHEN TO START?
1. Menses : within 5 days, if more than 5 days
need additional protection for the next 2 days
2. Amenorrhoea : start anytime if not pregnant,
additional protection for the next 2 days
3. Postpartum (breastfeeding) : 6 weeks – 6
months amenorrhoeic women with no
additional protection.
4. Postpartum (non breastfeeding) : less than 21
days can start immediately with no additional
 protection. >21 days with amenorrhoea can

Should be taken at or around the same time every day without a pill-
free intervals.
 • Indications for progestogen only pill :
1. Breastfeeding
2. Older age
3. Cardiovascular risk factor (high bp, diabetes)
 Injectable progestogens
• Depot medroxyprogesterone acetate (Depo-
Provera®/DMPA) - intramuscular injection
 Benefits
• Improve pre-menstrual syndrome (PMS)
• Treat menstrual problems such as painful or
heavy periods
• Treatment of endometriosis
• Useful for women who have difficulty
remembering to take a pill regularly.

Side effects
• Low oestrogen level Loss of bone mineral
 density
When to repeat?
• Every 3 months
• Can give up to 2 weeks earlier/later
• If >2 weeks later, can have the injection if
certain not pregnant but need additional
protection for the next 7 days.
Hormonal emergency contraception

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 Hormonal emergency contraception
• It is known as “morning after pill” or postcoital
contraception.
• Indications
– Unprotected intercourse
– Rape, sexual assault, incest
– Failure of contraceptive method
• Benefits
– Can save the lady of agony & from comitting
illegal abortion and even suicide
Gynaecology by Ten Teachers 19th edition

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 "morning-after pills," are drugs taken after
sexual intercourse intended to prevent
pregnancy.
Postinor 1 : One pill stat dose 1.5g
levonorgestrel now available through
pharmacies.

• Levonorgestrel (progestin) pills, marketed as

"Plan B" and "Next Choice," are available
 without prescription (to women and men aged

• Morning after pills have almost no health risk,

no matter how often they are used.

• Copper T-shaped IUDs can also be used as

emergency
WHO Medical eligibility criteria for contraceptive use 5th edition ‹#›
Contraceptives implant
(Implanon)
 Implanon

• Consists of single silastic rod

• Inserted subdermally under local anaesthetic
into the upper arm
• Releases progestogen etonogestrel 25-70 mg
(reduce in time) which is metabolized to the
third-generation progestogen desogestrel
• Lasts for 3 years
• Easily removed Gynaecology by Ten Teachers 19th edition

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Implanon

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Gynaecology by Ten Teachers 19th edition
 Implanon
• Benefits
– Useful for women who have difficulty to take a
pill
– Highly effective long-term contraception
• Risks
– Irregular bleeding
– Difficulty in removing

Gynaecology by Ten Teachers 19th edition

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 Intrauterine Contraception
• Ideal for those seeking medium to long-term
contraception, independent of intercourse and
regular compliance is not required.
• Protects against normal and ectopic
pregnancies, HOWEVER, if this form of
contraception fails, the pregnancy will have a
higher likelihood than normal of being ectopic
in nature.
• Insertion is performed by healthcare personnel,
mild to moderate discomfort, and is removable ‹#›
‹#›
 Types of IUCD
• Copper IUD – tend to be licensed for 10 years
of use, however, smaller ones may last up to 5
years. Effectiveness is proportionate to copper
content.
• Hormone-releasing IU system: Mirena uses a
capsule containing levonorgestrel around the
stem with 20micrograms released daily. Also
licensed for treatment of heavy menstrual
bleeding and HRT.
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 Risks of IUCD
• Perforation ( at the time of insertion)
• Pelvic infection
• Expulsion.
• If IUCD user becomes pregnant, higher
likelihood of ectopic.
• Menorrhagia
• Dysmenorrhoea
 Natural Method/ Rhythm
-Fertility Awareness Method [ FAM ]
-Natural Family Planning [ NFP ]
-Lactational Amenorrhea Method
-Temperature Method
-Rhythm/ Calendar Method
- Withdrawal
- Abstinence
 Fertility Awareness Method and
Natural Family Planning
• Sympto-thermal and mucus observation
approach
• 95-98% effective with perfect use (user strictly
follows rules to avoid pregnancy)
• Must have regular menstrual cycle
 Woman with regular menstrual
cycle
SYMPTO-THERMAL
Menstruation
AND MUCUS
OBSERVATION
Not feel or see
any mucus

Wet and slippery

mucus

No more mucus
and drier vagina
Advantages Disadvantages
- Effective method of birth control - Provides no protection from sexually
- Has no negative health side effects transmitted infections
- An alternative for women who cannot or -Often difficult to find trained FAM/NFP
do not want to use hormonal methods instructors
-Promotes positive body awareness -Requires time to learn (usually 3 to 6
-Consistent with many religious beliefs cycles)
and lifestyles -Requires discipline and commitment to
-Alerts women to reproductive health and chart fertility signs and follow the rules to
fertility concerns avoid pregnancy
-Fosters communication between partners -Times of abstinence from intercourse may
-Encourages partners to enjoy a variety of be a challenge for some couples
romantic or sexual activities as alternatives
to vaginal intercourse during fertile
periods
-Encourages male involvement
Lactational Amenorrhoea Method

Reference : [Link]
amenorrhea-method-lam-postpartum-contraception
Normal Physiology
• Used by a woman who has just given birth and
is exclusively breastfeeding
• Highly effective for the first six months after
childbirth, provided the woman breastfeeds the
baby at least every four hours during the day
and every six hours through the night, and that
her menstrual period has not yet returned
• After six months fertility may return at any
time
 3 Criteria
[1] a breastfeeding woman must be without
menses since delivery
[2] a woman must fully or nearly fully
breastfeed, and
[3] the infant must be less than six months old
 How to get efficient LAM?
- Breastfeed as soon as possible after birth
- Breastfeed frequently both day and night.
- Breastfeed exclusively for the first six months
- After the first six months when complementary foods are
introduced, breastfeed before giving complementary foods.
- Continue to breastfeed for up to two years and beyond.
- Continue breastfeeding even if mother or baby is ill.
- Avoid using bottles, pacifiers (dummies), or other artificial
nipples
- Mothers who are breastfeeding should eat and drink sufficient
quantities to satisfy their hunger and thirst.
Is there any difference if I give full
or partial BF?
- Very effective -Can only be used for a short period (up to
- Provides up to 0.5 CYPs (Couple Years six months postpartum)
Protection) -Requires breastfeeding frequently both
-Has no side effects day and night
-Does not require insertion of any device
at the time of sexual intercours
-May attract new family planning users
-Contributes to family planning
prevalence directly and through increased
acceptance rates
-Can be initiated immediately postpartum
-Is economical and requires no
commodities or supplies
-Contributes to optimal breastfeeding
practices and therefore enhances maternal
and infant health and nutrition
-Acceptable to all religious group
 Calendar Method
• Much less effective natural birth control
method
• It predicts a woman’s fertile days using
calculations based on the length of past cycles
[ at least do it for 8 cycles ]
SHORTEST : -18
LONGEST : -11
 Withdrawal
• Man withdraws his penis from a woman’s
vagina before ejaculation
• Both partners must be in agreement on this
method, and must be prepared to deal with an
unplanned pregnancy, which can occur in 1 out
of 5 users
 Abstinence
• Not to do something

Advantages
• Minimal risk of misuse
• Freedom from the threat of STI and HIV
infection, if no exchange of body fluids occurs
• No physical side effects
• No need to visit a health care provider
• No cost, unless condoms and dams are used for
oral-genital sex
 Barrier Method
• Barrier methods work by stopping sperm from
entering the vagina
• There are 3 main barrier methods of
contraception :
- Male condom
- Female condom
- Diaphragms
 Male Condom
• is a fine barrier which is rolled on to a man’s
penis before sex
• Prevent sperm from entering the vagina
• Protects user from sexually transmitted
diseases, including HIV
• Easy to get, easy to use, have no side effect and
help prevent cancer of the cervix
 Female Condom
• Is a pouch that is used during intercourse to
prevent pregnancy
• Reduces the risk of STI
• Inserted deep into the vagina just before
vaginal intercourse
• Cover the inside of the vagina and collect pre-
cum and semen when a man ejaculates. This
keeps sperm from entering the vagina
 Diaphragms
• fits inside the vagina and is used each time
you have sex.
• It covers your cervix (entrance to the uterus)
and stops sperm from getting through to join
an egg
• should always be used with spermicide
• Then remove it, wash and dry it and put it
away until next time you want to use it
• Protect cervix and from STIs
Sterilisation
 Sterilisation
• Permanent form of contraception
• But very occasionally can fail
• Done by:
individuals who feel family is completed
those who carry inherited disorders
those who do not want children

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 Consent
• Consent in writing is required
• Partner’s written consent is not asked for in
consent forms
• Consent forms clearly indicate:
that the procedure will be a permanent form of
contraception
some rare cases can possibly fail

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 Female sterilisation
Can be achieved by:
. Mechanical blockage of Fallopian tubes
• prevent sperm reaching and fertilizing the oocyte.
– Laporoscopy under general anaesthesia,
– mini-laparotomy with small transverse suprapubic incision,
– through the posterior vaginal fornix (colpotomy)
• Isthmus portion of Fallopian tube is the site for sterilisation

2. Removal of Fallopian tubes

3. Hysterectomy
Menstrual patterns are not directly altered

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• Suitable for • Damage • Easy to apply
postpartum mini- surrounding • Damage 2-3cm of
laparotomy structure tube
• Relative higher • Relative high failure • Reversal is difficult
failure rate rate

Electrocautery/ Fallope rings

Ligation
diathermy

• Technique of choice • Not widely used

• Simple to use • Very expensive
• May not fully techniques
occlude

Clips Laser
Female Sterilisation

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 Complications
• Anaesthetic problems

• Damage to intra-abdominal organs

• May need to proceed to mini-laparotomy (the uterus is

enlarged and more vascular) d/t difficulty to visualize the
pelvic organs at laparoscopy due to adhesions or obesity

• If it fails, 30% of pregnancies are likely to be ectopic

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 Male Sterilisation
Vasectomy
– Division of vas deferens to prevent release of sperm
during ejaculation
– Performed under local anaesthesia
– Technically and easier and quicker procedure than
female sterilization
– Easier, cheaper
– Slightly more effective than female
sterilization
 Not effective immediately – Why??
• Sperm will still be present higher in the
genital tract and azoospermia is therefore
achieved more quickly if there is frequent
ejaculation

• Hand in two samples of semen at 12 and

16 weeks to see if any sperm are still
present

• If 2 consecutive samples are free of

sperm, vasectomy can be considered

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 Complication of vasectomy
• Bleeding
• Wound infection
• Haematoma
• Sperm granulomas
• Anti-sperm antibodies
• Chronic scrotal pain
Sperm granuloma in the head of the left
epididymis. Extraductal spermatozoa are
very irritating and immunogenic, which
leads to the formation of granulomata.