FAMILY PLANNING

Presented by: PGIs Ilagan, Javier, Pena

Family Planning
• Contraception is warranted whenever the risk of giving
contraception outweighs the risk of getting pregnant
• Contraceptive method to employ is individualized
• No contraceptive method is completely without side effects
OVERVIEW OF MENSTRUAL
CYCLE
MENSTRUAL CYCLE
• Also known as ovarian-endometrial cycle
• Endometrial shedding with hemorrhage that is dependent on sex
steroid hormone-directed changes in the blood flow in the spiral
arteries
• Predictable, regular, cyclical and spontaneous
• Ideally 28 days (range: 25-35 days)
• Regulated by the hypothalamic-pituitary axis, ovaries and genital
tract
 Hypothalamic-pituitary-gonadal interplay
• Gonadotropin-releasing
hormone (GnRH)
secreted from
hypothalamus
stimulates anterior
pituitary to release FSH
and LH stimulates
ovarian follicles to
release estrogen and
progesterone
Follicle-stimulating Hormone (FSH)
• Initiates follicular growth by affecting granulosa cells
• Secretion is highest and most critical during the 1st week of
follicular stage
• Induce proliferation of granulosa cells and expression of LH
receptors on granulosa cells
Luteinizing Hormone (LH)
• Responded to by theca and luteal cells
• For growth of preovulatory follicles and luteinization and ovulation
of dominant follicle
ESTROGEN
• Secreted by the granulosa cells of the dominant ovarian follicle
• Predominant at the end of the follicular phase directly preceding
ovulation
PROGESTERONE
• Secreted at ovary by luteinized follicles (corpus luteum)
• Hallmark of luteal phase
• Luteal progesterone production decreases 🡪 signals the start of
menstruation
 Follicular Phase
• Induce androgen synthesis by theca cells
• Stimulates proliferation, differentiation
and secretion of follicular thecal cells
and increases LH receptors on granulosa
cells
Preovulatory LH surge
• Drives oocyte into 1st
meiotic division and
initiates luteinization of
thecal and granulosal
cells
• Resulting corpus luteum
produce high levels of
progesterone
• LH surge – triggers
ovulation
PHASES OF MENSTRUAL CYCLE
I. OVARIAN CYCLE
II. ENDOMETRIAL CYCLE
OVARIAN CYCLE ENDOMETRIAL CYCLE

A. FOLLICULAR PHASE A. PROLIFERATIVE PHASE

B. OVULATION PHASE B. SECRETORY PHASE

C. LUTEAL PHASE C. MENSTRUAL PHASE

D. PRE-MENSTRUAL
PHASE
OVARIAN CYCLE
• FOLLICULAR PHASE
- Pre-ovulatory phase
- Estradiol is the predominant hormone
- 3 PHASES OF FOLLICULOGENESIS
- Recruitment of cohort of antral follicles
- Selection of dominant follicle (Graafian follicle)
- Growth of selected dominant follicle
OVARIAN CYCLE
• OVULATION PHASE
• Increase in estrogen -> reaches threshold -> stimulate HPO axis -> further
increase of FSH and LH production -> reaches PEAK (absolute requirement
for final oocyte maturation)
• LH PEAK: 10-12 hours before ovulation
• Gives both proteolytic enzymes and inhibitors for tight regulation of
follicular rupture and formation of corpus luteum
OVARIAN CYCLE
• LUTEAL PHASE
• Development of Graafian follicle from corpus luteum
• HALLMARK: progesterone secretion
• LH is required for the maintenance of corpus luteum
• Life span: 14 days
• Without pregnancy – corpus luteum regresses 9-11 days after ovulation
via apoptosis
OVARIAN CYCLE
• PRE MENSTRUAL PHASE
• Decline of progesterone levels will signal the start of menstruation
ENDOMETRIAL CYCLE
• A. Proliferative
• B. Secretory
• C. Menstrual
ENDOMETRIAL CYCLE
• PROLIFERATIVE PHASE
- Proliferation of glandular, stromal and vascular endothelial cells
- Endometrial dating is difficult since it varies in length among women
- Counterpart of follicular phase in the ovarian cycle
- Ranges from 5 to 7 days to 21-30 days
ENDOMETRIAL CYCLE
• SECRETORY PHASE
- Highly predictable: 12-14 days
- Continuous development of spiral arteries
- Estrogen-primed endometrium responds to rising progesterone levels in a
highly predictable manner
- Day 20-24: window of implantation
ENDOMETRIAL CYCLE
• MENSTRUAL PHASE
- 3-5 days (2-7 days if regular)
- Average blood loss: 30ml (10ml-80ml)
- Initiated when production of progesterone in corpus luteum drops
- Leukocyte infiltration initiates the breakdown and repair of the
functionalis layer
Fertility – Awareness Based
Methods
1. C A L E N DA R C A LC ULAT IO N ( R HY TH M )
2. STA N DA R D DAYS M E TH O D ( S D M )
3. BA S A L B O DY TE M PE R ATU R E ( B BT )
4. C E RV I C A L M UC U S M E T H O D O R B IL LIN GS OV U LATI O N M E TH O D
5. SYM PTOTH E R M A L M E T H O D ( STM )
6. TWO - DAY M E TH O D
7. SA L IVA OV ULAT IO N M O N ITO R
8. LAC TATI O N A M E NO R R H EA M E TH O D ( LA M )
 ADVANTAGES DISADVANTAGES
1. Effective with correct and consistent use 1. Signs and symptoms of the fertile phase may vary
2. Very little or no cost 2. Irregular cycles can make these methods difficult
3. No drugs or physical devices needed; no and may inhibit sexual spontaneity
prescription required 3. Require high level of diligence and commitment
4. No medical follow-ups required from both partners
5. No medical contraindications 4. Require training for couples to accurately identify
6. No physical side effects the fertile period and how to effectively use it
7. Immediately reversible 5. Require consistent and accurate record keeping
8. No effect on breastfeeding or breast milk and paying close attention to bodily changes
9. Involve men and encourage shared responsibility 6. Can become unreliable or hard to use if the
for family planning woman has fever or vaginal infection
10. Promote better communication between spouses, 7. Require periods of sexual abstinence from vaginal
strengthening marriage and family intercourse, which may be difficult for some
couples
8. Does not protect against sexually transmitted
infections (STIs) including human
immunodeficiency virus (HIV) or autoimmune
disease syndrome (AIDS)
 1. CALENDAR RHYTHM METHOD
• Refrain from intercourse during fertile period
• Shortest recorded cycle minus 18 (start of the fertile period)
• Longest recorded cycle minus 11 (end of the fertile period)
• Depends on the length of prior cycles
• Success relies on the regularity of menses and strong motivation of
the couple
 2. STANDARD DAYS METHOD (SDM)
• Based on the physiology of the menstrual cycle and functional life
span of sperm and ovum
• Appropriate for women whose cycles are between 26 and 32 days
• Considered fertile on days 8 through 19
• No need to monitor other symptoms
• Color coded “cycle beads” to mark the fertile and infertile days
 3. BASAL BODY TEMPERATURE (BBT)
• Recommended for any reproductive age woman willing to take and
chart BBT daily and practice abstinence
• Refrain from intercourse from first day of menses until 3 days after
the temperature rise of 0.2 to 0.5C
• BBT is the waking temp before any activity
• Low point or nadir is appreciable within 1 to 2 days before the
Luteinizing Hormone surge
• BBT generally increases by 0.2 to 0.5C following ovulation
• Due to the thermogenic effect of pregnandiol which increases after
ovulation and is secreted by the corpus luteum
 4. CERVICAL MUCUS METHOD OR
BILLINGS OVULATION METHOD
• Recommended for any reproductive age woman without evidence of
vaginal infections or abnormal vaginal discharge
• Refrain from intercourse once the presence of a clear, wet and slippery
mucus secretion is observed until the 4 th day after her peak day of
wetness
• Fertile period is indicated by the feeling of “wetness” and presence of a
clear, wet and slippery mucus secretion
• The “peak day” is the last day of secretion
• Non-fertile period suggested by absence of mucus sensation, a “dry”
sensation, and the presence of a pasty, nonstretchy mucus or
unchanging mucus pattern a day after menstruation
 5. SYMPTOTHERMAL METHOD (STM)
• Recommended for any reproductive woman willing to take and
chart daily BBT, daily observations of cervical mucus, make a daily
records.
• Refrain from intercourse when the woman senses cervical
secretions, until both the 4th day after peak cervical secretions and
the 3rd full day after the rise in BBT
• Combination of BBT, cervical secretion observation and other signs
and symptoms of ovulation such as abdominal pain, cervical
changes, and breast tenderness
 6. TWO-DAY METHOD
• Recommended for reproductive age women without evidence of
vaginal infections or abnormal vaginal discharge
• Refrain from intercourse on the day and day after the woman
notices any secretions of any type, color and consistency
• Check cervical secretions ideally every afternoon and/or evening
• When secretions are noted, she is considered fertile on that day
and the day after
 7. SALIVA OVULATION METHOD
• Direct correlation between salivary ferning and fertile period
• Accuracy is close to 98% higher than other methods
• No food or fluid intake for at least 1 hour
• The mouth is rinsed with small amount of water and 5 more mins
of waiting before the test
• Saliva is collected under the tongue and placed in the center of a
scope
• Saliva is dried up after approximately 30 minutes
• Presence of ferning pattern corresponds to ovulation period
 EFFICACY
METHOD PERFECT USE (%) TYPICAL USE (%)
Billings Ovulation 97 80
BBT 99 80
STM 98 80
SDM 95 88
Two-Day 96.5 86

DISCONTINUATION
•Mainly due to:
• Difficulty learning
• Difficulty with use
• Challenge with sexual abstinence
• Lack of confidence
• Dissatisfaction
8. LACTATIONAL AMENORRHHEA METHOD
(LAM)
• Based on natural effect of breastfeeding on fertility
• Three requirements:
1. Monthly menstrual cycle has not returned
2. Fully or nearly breastfeeding
• Breastfeeding on demand
• 10 – 12 times a day with daytime feeding no more than 4 hours apart
• Night time feedings no more than 6 hours apart
3. Baby is less than 6 months old
• Production of natural hormones that cause ovulation is inhibited
with full or nearly full breastfeeding
 AVOID BREASTFEEDING
• Mother who is HIV positive
• WHO recommends HIV positive mothers to exclusively breastfeed for first
6 months of life unless replacement
• HIV-infected taking ARV may use LAM since there is reduction of HIV
transmission risk through breastfeeding
• HIV transmission is more likely among mothers with advanced disease or
who are newly infected
• Avoidance of breastfeeding is the strategy that may give Filipino infants of
HIV+ mothers the greatest chance of HIV-free survival
• Mother with active / untreated TB
• May resume if on TB medications for at least 2 weeks and is verified non-
infectious
• Mother with active herpes simplex virus (HSV) lesions on the
breast
• Expressed milk may be allowed for mothers with active HSV lesions on her
breasts and those who had varicella infection 5 days before through 2
days after delivery
BARRIER METHODS
1. MALE CONDOM
2. FEMALE CONDOM
 1. MALE CONDOM
• Latex made of a thin rubber sheath
• Polyurethane condoms appropriate for people with allergy
to latex and may provide protection against STIs
• Sheepskin condoms allow passage of Hepa B, HSV and HIV
• Stored in a cool, dry place with temp not exceeding 37.7C
and not below 0C
• Advised to use non-oil based lubricants with latex condoms
• Spermicidal lubricants do not provide additional protection
against pregnancy or STIs
• Efficacy: 98% with perfect use; 85% with typical use
• Effective in preventing transmission of HIV and reducing the risks
of other STIs
• Only contraindication:
• Allergy to latex
 2. FEMALE CONDOM
• Soft, loose-fitting polyurethane sheath
• 7.8cms in diameter and 17cm long
• 2 flexible rings: one attached to the sheath, other unattached
• For additional lubricants needed:
• Clean water
• Saliva
• Oil
• Lotion
• Any oil-based lubricant
• Should be inserted just prior or up to 8 hours before intercourse
• Remove immediately after intercourse
• Effectiveness: 95% perfect use; 79% typical use
• Need to practice insertion prior to actual use
 HORMONAL METHODS
I. COMBINED HORMONAL CONTRACEPTIVES
II. COMBINED INJECTABLE CONTRACEPTIVES (CIC)
III. COMBINED VAGINAL RING CONTRACEPTION (CVR)
COMBINED ORAL CONTRACEPTIVES
I. CLASSIFICATION

A. Amount of Estrogen
(EE) used

B. Type of Progestin used

COMBINED ORAL CONTRACEPTIVES
A. According to Amount of Estrogen Used
1. First Generation
- contains 50 mcg or more
2. Second Generation
- less than 50 mcg
3. Third Generation
- ranges from 20-35 mcg
COMBINED ORAL CONTRACEPTIVES
A. According to Type of Progestin Used
1. First Generation
- 10 times the dose compared to previous generations
- ex: Norethidone, Norethidone Acetate, Ethynodiol diacetate
I. COMBINED ORAL CONTRACEPTIVES
A. According to Type of Progestin Used
2. Second Generation
- more potent, produces anovulatory effect at lower doses
ex: Levonorgestrel (LNG), Norgestimate
COMBINED ORAL CONTRACEPTIVES
A. According to Type of Progestin Used
3. Third Generation
- contains gonane progestins (ex: Desogestrel or Gestodene)
- have reduced androgenic and metabolic side effects
COMBINED ORAL CONTRACEPTIVES
A. According to Type of Progestin Used
4. Fourth Generation
- contains Drosperinone, dienogest or normegestrol acetate
PHASIC PILLS
• Reduces total progestin per cycle without sacrificing the
contraceptive efficacy or cycle control

TYPES OF PHASIC PILLS

• Monophasic Pills
• Biphasic pills
• Triphasic pills
• Quadriphasic pills
 PHASIC PILLS
• Monophasic Pills
• Provide same amount of estrogen and progesterone in every pill
• Biphasic pills
• First 10 pills with one dosage next 11 pills with another level of estrogen and
progestin
 PHASIC PILLS
• Triphasic pills
• 1st 7 pills same dosage, next 7 pills another dosage and last 7 pills with
another dosage
• Quadriphasic pills
• Contains a bioidentical synthetic estrogen, estradiol valerate and dienogest
• Offers a progestin/estrogen dosing combination during each 28 day cycle
MECHANISM OF ACTION- COC
• Low-dose COCs prevent pregnancy by:

1. Estrogen prevents ovulation by suppressing FSH release

2. Progestins prevent ovulation by suppressing LH release and thickening

cervical mucus hence preventing sperm passage
 Monthly COCs
• 21 pills
- 21 active tablets everyday followed by 7 pill-free days
• 22 pills
- 22 active tablets everyday followed by 6 pill-free days
• 24 pills
- 24 days active pills taken everyday followed by 4 pill-free days
• 28 pills
- 21 active pills everyday followed by 7 inactive or reminder pills of a different
color
- No hormone content for reminder pills
- No pill-free days
HOW TO TAKE COCs
• One pill daily, preferably at the same time every day
• Start within 5 days of the menstrual period, can be started anytime
if not pregnant but a back up method is required for 7days if
started after the 7th day of menses
MISSED PILLS
• Take missed pills as soon as possible then keep taking pills as usual

• When 1 or 2 pills are missed or a new pack is started 1 or 2 days

late:
• Take 1 pill as soon as possible
• No back up required
MISSED PILLS
• When 3 pills are missed in a row in the 1st or 2nd week or a new
pack is started 3 days late, or 3 pills missed in the third week:
• Start a new pack right away
• Use back up method for the next 7 days
• If vaginal intercourse done in the past 5 days, consider emergency
contraception

• If she vomits within 2 hours after taking a pill, another pill should
be taken as soon as possible
 SAFETY
• COCs do not disrupt existing pregnancy
• COCs do not cause birth defects/teratogenic

EFFECTIVENESS
• COCs have a 99.7% and 92% effectiveness with perfect and typical use
DRUG INTERACTIONS
• COCs effectiveness is reduced by the following drugs:
• Rifampicin, Phenytoin, Phenobarbital, Carbamazepine, Primidone,
Ethosoximide

• Anticonvulsants that induce hepatic enzymes can decrease serum

concentrations of hormonal content of COC

• Most broad spectrum antibiotics do not affect effectiveness of

COCs
SIDE EFFECTS
• Most common during first 3 months of use
• Spotting, amenorrhea, nausea, breast tenderness, headaches and
depression

• There is no delay of return to fertility after COCs are discontinued.

 SPECIAL GROUPS
1. Smokers 6. Dyslipidemia
2. Women older than 40 7. Diabetes mellitus
3. Postpartum/Breastfeeding 8. Cancer
Women 9. Thromboembolism
4. Obesity 10. Migraine/Headaches
5. Hypertension
SMOKERS
• COC should not be used for women older than 35and who smokes
15 sticks or more per day (Level I, Grade A)
• There is a high risk for myocardial infarction among smoking
women who used 50 mcg or more of estrogen
WOMEN OLDER THAN 40
• Healthy, nonsmoking women doing well on COC cam continue
their method until menopause after weighing the risks and
benefits
• No increased risk of MI or stroke on healthy nonsmoking women
older than 35 years who used less than 50 mcg of estrogen.
POSTPARTUM/BREASTFEEDING WOMEN
• Pregnancy is a hypercoagulable state until 3 weeks postpartum
(PP) hence
• COCs are started anytime after 3 weeks postpartum if client is not
breastfeeding and do not have any other risk for venous
thrombosis
• Risk for venous thromboembolism (VTE) within the 1st 42 days PP
is 22 to 84 fold greater than the risk among nonpregnant
POSTPARTUM/BREASTFEEDING WOMEN
• Risk is highest immediately after delivery, declines rapidly durig 1st
21 days but not returning to baseline until 42 days PP
• COCs are not recommended as 1st choice for breast feeding
women due to negative effect of estrogen on lactation
• Return of ovulation after an abortion of a fetus less than 12 weeks
gestation is as early as 2 weeks hence COC can be started
immediately
 OBESITY
• Obese women older than 35 years old has increased risk for VTE

HYPERTENSION
• COCs can be prescribed to healthy, non smoking clients 35 years or
younger with well controlled and monitored hypertension with no
signs of end organ vascular disease
 DYSLIPIDEMIA
• COCs can be appropriate for healthy, non smoking women with known
dyslipidemia without other known cardiovascular risk factors

DIABETES MELLITUS
• COCs can be prescribed to healthy, non smoking clients 35 years or
younger with no evidence of nephropathy, retinopathy or oter
vascular diseases
 CANCER
• Personal history of benign disease or family history if breast cancer is
NOT a contraindication for COCs
• COCs reduces the risk of both Endometrial and Ovarian Cancer

THROMBOEMBOLISM
• COCs are not recommended for women with documented history of
VTE
FOLLOW UP
• Advised to return 3 months after the initiation of COC then
annually there after or if problems arise
• Ex: Jaundice, Severe Abdominal pain, Chest Pain, Severe
Headaches, Eye problems-loss of vision, flashes, and Severe Leg
Pain
Summary - COC
• Missing the pill is the most common cause of contraceptive failure
and COC side effects like spotting or withdrawal bleeding
• WHO working group determined that missing 3 or more active pills
(2 or more for 20 mcg or less EE pills) at any time during the cycle
needs additional precautions
• Risk of pregnancy is greatest when active pills are missed at the
start or end of the active pill taking period
• WHO working group recommends a back up method when missing
20 mcg or less
II. COMBINED INJECTABLE CONTRACEPTION
(CIC)
• Contains estrogen and progestin in an injectable form given
monthly (every 30 +/- 3 days)
• First injection given on 1st day of menstrual cycle

• Advantages
1. Does not require daily action; no daily pill intake
2. Private no one can tell if client uses contraceptive
3. More regular bleeding as compared to DMPA
FORMULATION
• Norifam
• Contains norethisterone 50 mg and
• Estradiol valerate 5 mg in oily solution
 III. COMBINED VAGINAL RING
CONTRACEPTION (CVR)
• Vagina is an ideal site for hormonal
absorption
• Stratified squamous epithelium, not
cornified premits easier penetration
to vascular lamina propia
• No hair follicles, and fat cells that can
interfere in drug absorption
• Avoids the 1st pass effect
FORMULATION- CVR
• Flexible, soft, transparent ring
containing crystals of EE and
etonogestrel
• Available in one size, 4mm thick 54
mm diameter
• Releases 15 mcg EE and 120 mcg of
etonogestrel daily
• Ring is inserted by client and worn
for 3 weeks
 PROGESTIN-ONLY
CONTRACEPTIVES
1. PROGESTERONE-ONLY SUBDERMAL IMPLANTS
2. INJECTABLES
3. PILLS
PROGESTIN-ONLY CONTRACEPTIVES
• More suitable options for women who have absolute or relative
contraindications to estrogen use
• Thrombophilias
• Smokers over the age of 35
• Hypertensive
• Those who experience migraines with associated neurologic symptoms

• Mechanism:
• Thickens cervical mucus within 48 hours of use prevents sperm
penetration
• Inhibits ovulation via negative feedback inhibition of FSH and LH
• Consequent thinning and atrophy of endometrium
 I. PROGESTIN-ONLY PILLS
• “Mini-pill”
• Come in either 28-day packs or 35-day packs and all the pills
within a pack contain same kind and amount of progestin
• Recommended for breastfeeding women, those with
cardiovascular problems and smokers
• Should be taken at the same time every day, with no pill-free
interval
• If a POP is taken 3 hours later (lynestrenol) or 12 hours later (desogestrel)
or missed a pill completely, should take the missed pill as soon as possible
and continue taking the rest of the pills as usual, one each day*
• Can be started at any time during the menstrual cycle
• However, if not started within the first 5 days of menses, a back up
contraceptive is required for 2 days
 I. PROGESTIN-ONLY PILLS
• Adverse Effect
• Altered bleeding pattern – most common reason for discontinuation
• Headache
• Bloating
• Acne
• Breast Tenderness
 I. PROGESTIN-ONLY PILLS
• Special groups
• Non-breastfeeding women of less than 3 weeks postpartum may be
started on POPs within 21 days postpartum
• Beyond 3 weeks postpartum with no resumption of monthly bleeding may
be started on POPs with back up contraception for the first 2 days of pill
intake
• Breastfeeding women less than 6 week to 6 months postpartum may be
started on POPs
 I. PROGESTIN-ONLY PILLS
• Follow up
• After 1 month of initial visit or earlier if with problems
• Before discontinuation of breastfeeding, as shifting to another form of
contraception should be discussed
 II. INJECTABLE PROGESTIN
CONTRACEPTIVES
• Two types:
• Depot medroxyprogesterone acetate (DMPA) given every 3
months
• Norethisterone enanthate (NET-EN) given every 2 months
• Good option for women inconvenienced of daily dosing
of contraception
• 3 Formulations:
• DMPA-IM: 150mg injected intramuscularly
• DMPA-SC: 104mg given subcutaneously
• NET-EN: 200mg given intramuscularly into the deltoid or
gluteus muscle
 II. INJECTABLE PROGESTIN
CONTRACEPTIVES
• Good option for:
• Women with hypertension (≤160/100mmHg)
• Diabetes mellitus of NMT 20 years in duration
• Past history of cardiovascular disease, stroke, kidney disease, migraine
headaches without aura, varicose veins or thrombophlebitis
• Postpartum and post-abortal patients
• Breastfeeding mothers
 II. INJECTABLE PROGESTIN
CONTRACEPTIVES
• Proper use:
• No back-up method is necessary if given:
• During the first 7 days of menstrual cycle
• Immediately after or during the first 14 days post-abortal
• During the first 21 days after delivery if not breastfeeding
• Between 6 weeks and 6 months in a fully breastfeeding woman
 II. INJECTABLE PROGESTIN
CONTRACEPTIVES
• Contraindication: current pregnancy and breast cancer
• Side effects:
• Unscheduled bleeding due to thinning endometrium
• Usually during the first 6-9 months
• Reversible decrease in bone mineral density
• Return to fertility on the average is 9-10 months upon discontinuation of
DMPA and 6 months after the last NET-EN injection
 III. PROGESTIN SUBDERMAL IMPLANTS
• Thin, pliable progestin-containing cylinders that are
implanted subdermally and release hormone in over
many years
• Maintain low but stable serum hormonal levels
minimizing metabolic effects
• May be used as contraception for 3 years then replaced
at the same site or in the opposite arm
• Etonorgestrel implant: the only FDA-approved
implantable contraceptive
• Mechanism: inhibition of ovulation and increase in
cervical mucus viscosity
 III. PROGESTIN SUBDERMAL IMPLANTS
• Proper Use
• Can be inserted within 7 days of menses
• Can be inserted more than 7 days since start of menstrual bleeding if it is
certain that the woman is non-pregnant
• Postpartum women who are fully or near fully breastfeeding may receive
an implant less than 6 weeks postpartum up to 6 months PP
• Non-breastfeeding, postpartum women can receive the implant within 21
days postpartum
• Postabortal women can immediately receive the implant
 III. PROGESTIN SUBDERMAL IMPLANTS
• PSI may be removed anytime, with fertility returning as early as 42
hours after removal
• Side effects: menstrual irregularity, amenorrhea
• Adverse effects: weight gain (3-4 lbs/yr), mood changes, headache,
acne, breast pain and depression, implant site complications (i.e.
swelling, redness, hematoma, pain)
• Special Groups: suitable for adolescent age group
 EMERGENCY CONTRACEPTION
• M E TH O D O F PR E V E N TIN G PR EGN A N C Y A F TE R UN PROTEC TE D VAGI NA L
I NT E RCO U RSE
• I MP LIES A N A F TE R CO ITU S A PP ROAC H TO PR EGN A N CY PR E V E N TI O N
• I NT E N D E D TO B E US E D O C C A S I O N A LLY O R A S A BAC KU P
1. Levonorgestrel Emergency Contraception
(LNG)
• Gold standard for oral emergency contraception
• If taken before ovulation, they inhibit the pre-ovulatory LH surge,
impeding follicular development and maturation and/or the
release of the egg
• If given during fertilization, no adverse effect on the ensuing
pregnancy
• NOT an abortifacient and can be used at any time during the
menstrual cycle after unprotected vaginal sex
• No effect on the histological and biochemical characteristics of the
endometrium
• Not commercially available in the Philippines
• Single dose 1.5mg immediately up to 72 hours after
• 0.75mg taken 12 hours apart
• Most effective when given within 72 hours but can be given up to 5
days after unprotected vaginal intercourse
• Pregnancy rate with use is 1.7% to 2.6%
• Pregnancies prevented:
• 95% if used within 24 hours
• 85% if used within 25-48 hours
• 58% if used within 49 – 72 hours
• Refrain from unprotected intercourse after using LNG until menses
• Failure usually happens when there is repeated exposure after use
and prior to menses
• Repeat dose may be given when a patient experiences vomiting
within 2 hours of intake
• Anti-emetics may be given to those who vomit within 2 hours of
LNG intake
• Side effects
• Usually resolve within 24 hours
• Headaches
• Nausea
• Abdominal pain
• Menstruation may come 1-2 days earlier
• No association with adverse pregnancy outcome or congenital anomaly
 2. THE YUZPE AND LANCE REGIMEN
• Use of regular oral contraceptive pills containing both ethinyl estradiol (EE)
and LNG or di-norgestrel at a combined total dosage of 0.1mg EE and
0.5mg LNG or 1mg di-norgestrel
• Fertilization and blastocyst implantation and development are not affected
• Inhibits follicular development after the selection of the dominant follicle
and before LH rise
• Cause either delay or arrest of follicular rupture
• If given before the selection of the dominant follicle or when LH begins to
rise, ovulation proceeds unimpended
• Established pregnancies are not aborted
• Initial dose started as soon as possible and at most within 72 hours
and repeated 12 hours after
• Can be used at any time within the menstrual cycle
• Has a weaker efficacy compared to LNG
• Side effects:
• Usually midl
• Nausea
• Vomiting
• Change in bleeding pattern
• Anti-emetic should be given to those who vomit within 2 hours, 1-
2 hours before repeating the dose
• Side effects are more prominent than with LNG ECP
 3. ULIPRISTAL ACETATE
• Selective progesterone receptor modulator
• Has a mixed progesterone agonist and antagonist effects in the
myometrium and endometrial tissues
• Acts on the endometrium and inhibits ovulation
• If taken before ovulation
• Suppression of estradiol levels causing a delay in development of the follicle and
release of ovum
• If taken during LH peak
• Delay in rupture of follicle and release of ovum
• If taken in the latter part of the cycle
• Decrease endometrial thickness
SPECIAL SITUATION REQUIRING EMERGENCY
CONTRACEPTION
• Missed 3 or more combined oral contraceptive or 3 days late starting
subsequent pack
• 4 weeks or more delayed in her next dose of DMPA
• Failed to abstain during the fertile period if using FAB method
• Failed to withdraw prior to ejaculation
• For those taking POP: if 3 or more hours late with dose and anytime
afterwards until POPs are correctly taken for 2 days or more
• Should be given within 28 days following intake of liver enzyme inducers
• If with deliberate removal or spontaneous expulsion of IUD
INTRAUTERINE METHODS
• SMALL CONTRACEPTIVE DEVICES INSERTED THROUGH THE
CERVIX AND POSITIONED INTO THE UTERINE CAVITY
 COPPER IUD LEVONORGESTREL INTRAUTERINE
SYSTEM
• T-shaped plastic device with a tring of • Consisting of a polyethylene T-shaped
copper wrapped around the stem and frame, with a steroid reservoir around
copper bands on its arms the 32mm long vertical system
• Two-stranded monofilament tail that • Contains 52mg of LNG mixed with
protrudes through the cervical canal polydimethylsiloxane
into the upper part of the vagina • Releases approximately 20 ug LNG per
• No hormone day reducing to 10ug per day after 5
years
• Mediates its action via hormone
Mechanism of Action
• Inhibits sperm transport into the upper genital tract and inhibition
of ovum transport
• Active substances released from the devices combined with
products derived from the inflammatory reaction are toxic for the
spermatozoa and oocytes
• Prevents fertilization
 IUS
• Increases the thickness of the cervical mucus
• May prevent the release of an egg from the ovary
• With high concentrations of LNG, causes suppression of
endometrial proliferation and decidualization of stroma
 Risk Factors for STI
• Sexually active at age < 25 years
• New sexual partner in the last 3 months
• More than one sexual partner in the last year
• Regular sexual partner who has other sexual partners
• History of STIs
• Attending as a previous contact of STI
• Alcohol / substance abuse

• Tests for Chlamydia trachomatis and Neisseria gonorrhea should be

done before insertion
 Use of Prophylactic Antibiotics at the time
of IUD Insertion
• Not routinely required for insertion or removal even in women at
risk for infective endocarditis
• Risk of infection limited to first few weeks to months after
insertion of IUD
• Related mostly to contamination of endometrial cavity
• Insertion of an IUD may cause pain and discomfort for a few hours
and light bleeding for a few days
 IUD/IUS can be inserted:
• Anytime during the menstrual bleeding (Day 1 – 7)
• Anytime during the menstrual cycle provided that it is reasonably
certain that the woman is not pregnant
• Immediately after a non-septic abortion
• Anytime within 48 hours after childbirth
• During CS prior to closure of uterus
• From 4 weeks postpartum
• Immediately when shifting to another method which was used
correctly and accurately
 DISCONTINUATION
• Can be removed anytime
• Most common reasons for discontinuation:
• Desire for pregnancy
• Unacceptable vaginal bleeding
• Pain
• Infection
• Main reason for discontinuation: amenorrhea
• Precautions
• Increased risk of infection
• Uterine perforation
• Vaginal bleeding
 SIDE EFFECTS
• Heavy menstrual bleeding • Possible acne
• Dysmenorrhea
• During the first 6 months
• Irregular bleeding
• Spotting
• End of first year use
• Oligomenorrhea
• Amenorrhea
• No significant weight gain
 RECOMMENDATIONS
• Maybe used by those with • Safely used during breastfeeding
migraine • May be used with BMI over 30
• Risk of ectopic pregnancy is
lower with IUD than with no
contraception
• No delay in return of fertility
following removal or expulsion
• Not contraindicated in
nulliparous
• Safe and appropriate for
adolescents
 FOLLOW-UP
• Recommended after the first menses, or 3 – 6 weeks after
insertion
• TVS for visualization of IUD string not recommended*
• Instruct patients how to palpate for strings
STERILIZATION METHODS

1. TUBAL LIGATION (FEMALE STERILIZATION)

2. VASECTOMY (MALE STERILIZATION)
 I. TUBAL LIGATION
• Commonly known as bilateral tubal ligation (BTL)
• Done by transection each fallopian tube along its length
• The client and spouse must have understood and signed an informed
consent form after preoperative counseling
• Additional counseling should be given to those younger than 30 years
of age, those who do not have children or with low parity
• Best to be performed on the first 7 days of menstrual cycle
• Postpartum sterilization is preferably done between 2 to 7 days post-
delivery
I. TUBAL LIGATION
 Modified
Pomeroy Method
After transfixing a suture in an avascular
area of the mesosalpinx, proximal side
of the tube is tied then the distal side of
the looped tube is secured with a
square knot, and the tube is excised.
Parkland Method
An avascular site in the mesosalpinx adjacent
to midportion of the FT is identified and
perforated using a small hemostat.

FT is carefully separated from the

mesosalpinx. And the freed FT is ligated both
proximally and distally with chromic-0
suture.

The intervening segment (~2cm) is then

excised.
Long-term Complications
• Pregnancy following sterilization is uncommon
• Risks: subsequent ectopic pregnancy, increased chance of irregular
menses
• May fail for two major reasons:
• Surgical errors (i.e. transection of round ligament or partial transection of
tube)
• Fistulous tract or spontaneous re-anastomosis between severed stumps
 II. VASECTOMY
• Vas deferens lumen is occluded to block the passage of sperm
from the testes through a small incision
• DISADVANTAGE: sterilization is not immediate
• Complete release of sperm takes ~3 months or 20 ejaculations
• During this time, another contraception should be used
• Failure result from unprotected sexual intercourse too soon after ligation
THANK YOU!