DEMOGRAPHY AND FAMILY

PLANNING
[Link] RAIKWAR
 EFFECTIVENESS OF IUDs
• Most effective reversible contraceptive method.
• Oral and Injectable contra.> IUDs
• Longer continuation rates than hormonal and
injectables.
• Copper devices are more effective than lippes
loops
• .The effectiveness of copper devices is directly
related to the amount of copper surface area.
 Change of IUDs
• Inert IUDs such as Lippes Loop may be left in
place as long as required.
• Copper IUDs --- They have to be replaced
periodically. Or same with hormonal IUDs.
• Cu-T-380 A ---- 10 years
• Cu-T-200---- 4 years
• Nova-T------ 5 years
• Progesterone release IUDS---- every year.
• Levonorgesterol IUDs------ 7 years
 ADVANTAGES
• Simplicity i.e. No complex procedure invoved.
• No hospitalization is required.
• Insertion takes only a few minutes.
• Once inserted IUDs stay in place as long as
required.
• Inexpensive
• Contraceptive effect is reversible by removal of IUD.
• Free of systemic metabolic side effects.
• Highest continuation rate.
 CONTRAINDICATIONS
• ABSOLUTE—
• Suspected pregnancy.
• Pelvic inflammatory disease.
• Vaginal bleeding of undiagnosed etiology.
• Cancer of the cervix, uterus, adnexia and
other pelvic tumours.
• Previous Ectopic pregnancy.
 CONTRAINDICATIONS
• --RELATIVE
• Anaemia
• Menorrhagia
• History of PID since last pregnancy.
• Purulent cervical discharge.
• Distortions of uterine cavity due to congenital
malformations, fibroids.
• Unmotivated person
 IDEAL IUD CANDIDATE
• The planned parenthood federation of America
has described ideal candidate—
• Who has born at least one child
• Has no history of pelvic disease.
• Has normal menstrual period.
• Is willing to check the IUD tail.
• Has access to follow up and treatment of
potential problems.
• Is in a monogamous relationship.
 TIMING OF INSERTION
• It can be inserted during menstruation or within 10
days of the beginning of the menstrual period.
• During the first week of the delivery. (immediate
postpartum insertion)
• After 6 weeks postpartum(post puerperal
insertion ).
• Immediately after legally induced first trimester
abortion.
• Immediate insertion is not recommended after
second trimester abortion.
 INSERTION OF IUCD
• Gentle “ WITHDRAWL– TECHNIQUE”
 FOLLOW UP AFTER INSERTION
• Client should be asked to check the thread after
every menstrual cycle to ensure that it is insitu.
• They must return for follow up after the first
menstruation following IUCD insertion.
• Report when warning signs appear—
• Missed period, abdominal pain ,pain during
intercourse,local infection or foul smelling
discharge , fever chills and spontaneous infection
 SIDE-EFFECTS AND COMPLICATIONS
• BLEEDING
• PAIN
• PELVIC INFECTIONS ( PID)
• UTERINE PERFORATION
• PREGNANCY
• ECTOPIC PREGRANY
• EXPULSION
 SIDE -EFFECTS
• FERTILITY AFTER REMOVAL
• CANCER AND TERATOGENESIS
• MORTALITY
 Combined oral
contraceptive pills (COCS)

13
 GONADAL STEROIDS
• TERM “Steroid” refer to adrenocortical
hormones, while to those in gynaecology, it
implies gonadal steroids, i.e. , oestrogens and
progestogens.

• a. Synthetic oestrogens : ethiny/-oestradiol and

mestranol.
• b. Synthetic progestogens : pregnanes,
oestranes and gonanes.
 GONADAL STEROIDS
• a. Synthetic oestrogens :
– Two synthetic oestrogens are used in oral contraceptives. - ethiny/-
oestradiol and mestranol.
– Mestranol is inactive until converted into ethinyl oestradiol in the liver .
• b. Synthetic progestogens :
– (i) Pregnanes : These include megestrol, chlormadinone and
medroxyprogesterone acetate.
– The pregnane progestogens are not recommended in oral contraceptives
because of doubts of breast tumours in beagle dogs.
– (ii) Oestrones: These are also known as 19-nortestosterones, e.g. ,
norethisterone, norethisterone acetate , lynestrenol, ethynodiol diacetate
and norethynodrel. These are all metabolized to norethisterone before
becoming active.
– For some women, oestranes are more acceptable than gonanes.
– (iii) Gonanes: The most favoured gonane is levonorgestrel .
Classification of Hormonal Contraceptives
• A. Oral pills
– 1. Combined pill
– 2. Progestogen only pill (POP)
– 3. Post-coital pill
– 4. Once- a-month (long-acting) pill
– 5. Male pill
• B. Depot {slow release) formulations
– 1. lnjectables
– 2. Subcutaneous implants
– 3. Vaginal rings
 Combined Pills
• Major spacing methods of contraception.
• The "original pill“ marketed in the early 1960s
contained 100- 200 mcg of a synthetic oestrogen
and 10 mg of a progestogen.
• Since then, to reduce the undesirable side-effects of
the pill the dose of both oestrogen and progestogen
were reduced.
• Presently marked combined pill contain no more
than 30- 35 mcg of a synthetic oestrogen, and 0.5 to
1.0 mg of a progestogen.
 Combined Pills
• Dosing - The pill is given orally for 21 consecutive days
beginning on the 5th day of the menstrual cycle, followed by
a break of 7 days during which period menstruation occurs.
• When the bleeding occurs, this is considered the first day of
the next cycle.
• The bleeding which occurs is from an incompletely formed
endometrium caused by the withdrawal of exogenous
hormones. Therefore it is called "withdrawal bleeding"
rather than menstruation.
• If bleeding does not occur, the woman is instructed to start
the second cycle one week after the preceding one.
 Combined Pills
• The pill should be taken everyday at a fixed time,
preferably before going to bed at night.
• The first course should be started strictly on the
5th day of the menstrual period, as any deviation
in this respect may not prevent pregnancy.
• If the user forgets to take a pill , she should take it
as soon as she remembers, and that she should
take the next day's pill at the usual time .
 How to take COCs
Take one pill each day, by mouth.
If you use the 28-pill pack:
• No waiting between packs.
• Once you have finished all the pills in the pack,
start new pack on the next day.
28-pill pack

If you use the 21-pill pack:

• 7 days of no pills
• Once you have finished all the pills in the pack,
wait 7 days before starting new pack. For
21-pill
21-pill pack
pack example: If you finish the old pack on Saturday,
take the first pill of the new pack on the following
Sunday.
Waiting too long between packs greatly increases risk of pregnancy.
Adapted from Training Resource Package for Family Planning: [Link]
 COCs: Missed pills instructions
Miss 1 or 2 active pills in a row or start a pack 1 or 2 days late:
Always take a pill as soon as possible.
Continue to take one pill every day.
No need for additional protection.

Miss 3 or more active pills in a row or start a pack 3 or more days late:
• Take a pill as soon as possible, continue taking 1 pill each day, and use condoms or
avoid sex for next 7 days. If she had sex in the past 5 days, she can consider ECPs.

AND OR
• If these pills missed in week 3, ALSO skip the
inactive pills in a 28-pill pack and start a new pack week 3

• If the inactive pills are missed, throw away the

missed pills and continue taking pills 1 each day
Adapted from Training Resource Package for Family Planning: [Link]
Family Planning: A Global Handbook for Providers (3rd Edition, 2018)
 Combined Pills
• Type of Pills –
• The Department of Family Welfare, Government of India has
made available 2 types of low-dose oral pills under the brand
names of MALA-N and MALA- D.
• It contains Levonorgestrel 0 .15 mg and Ethinyl estradiol 0.03
mg.
• Mala-D in a package of 28 pills (21 of oral contraceptive pills and
7 brown film coated 60 mg ferrous fumarate tablets) is made
available to the consumer under social marketing at a price of
Rs. 3 per packet.
• Mala- N is supplied free of cost through all PHCs,
• urban family welfare centres.
 COCs: Summary
• Safe for almost all women
• Effective if used consistently
and correctly
• Fertility returns without a
delay
• Screening and counseling are
essential

Adapted from Training Resource Package for Family Planning: [Link]

 Progestogen-only pill (POP)
• Referred to as ·'minipill" or "micropill ".
• Only progestogen, in small doses throughout the cycle.
• Commonly used are norethisterone and levonorgestrel.
• These pills never gained widespread use because of poor
cycle control and an increased pregnancy rate.
• They could be prescribed to older women for whom the
combined pill is contraindicated because of cardiovascular
risks.
• Also be used in young women with risk for neoplasia.
• Evidence that the progestogens lower the high-density
lipoproteins may be of concern.
 Post Coital Contraception
• Post-coital (or "morning after") contraception is recommended
within 72 hours of an unprotected intercourse.
• (a) IUD : The simplest technique is to insert an IUD, if acceptable,
especially a copper device within 5 days.
• (b) Hormonal : Preferable. In India Levonorgestrel 0. 75 mg tablet
is approved for emergency contraception. It is used as one tablet
of 0. 75 mg within 72 hours of unprotected sex and the 2nd tablet
after 12 hours of 1st dose.
or
• Two oral contraceptive pills containing 50 mcg of ethinyl estradiol
within 72 hours after intercourse, and the same dose after 12
hours.
 Post Coital Contraception
• (b) Hormonal : Cont..
or
• Four oral contraceptive pills containing 30 or 35 mcg of ethinyl
estradiol within 72 hours and 4 tablets after 12 hours.
or
• Mifepristone 10 mg once within 72 hours.
 Post Coital Contraception
• Post-coital contraception is advocated as an emergency method;
for example, after unprotected intercourse, rape or contraceptive
failure.
• Although the failure rate for post-coital contraception is less than
1 percent.
 Once-a-month (long-acting) pill
• Once-a-month oral pill in which quinestrol, a long-acting
oestrogen is given in combination with a short-acting progestogen,
have been disappointing.
• The pregnancy rate is too high to be acceptable.
• Also bleeding tends to be irregular.
 Male pill
• Research is following 4 main lines of approach
• (a) preventing spermatogenesis
• (b) interfering with sperm storage and maturation
• (c) preventing sperm transport in the vas, and
• (d) affecting constituents of the seminal fluid .
• A male pill made of gossypol - a derivative of cotton-seed oil, has
been very much in the news.
• 10 per cent of men may be permanently azoospermic after taking
it for 6 months.
 MODE OF ACTION OF ORAL PILLS
• MOA– To prevent the release of ovum from
the ovary.
• By blocking the pitutary secretion of
gonadotropins.
• POPs render the cervical mucus thick and
scanty.
• Progesterone also inhibits tubal motility.
 COCs: Characteristics
• Most women can safely use • Less effective when not used
the pill correctly (91%)
• Safe and more than 99% • Require taking a pill every
effective if used correctly day
• Can be stopped at any time • Do not provide protection
• No delay in return to fertility from STIs/HIV
• Are controlled by the woman • Have side effects
• Do not interfere with sex
• Have some health risks (rare)
• Have health benefits

32
Adapted from Training Resource Package for Family Planning: [Link]
 COCs: Health benefits
Menstrual Others
• Decreased amount of flow • Protection from Risks of pregnancy,
and fewer days of bleeding; ovarian cancer and endometrial
no bleeding (less common) cancer and symptomatic PID

• Regular, predictable • Reduced risk of ovarian cysts and

iron-deficiency anemia
menstrual cycles
• Decreased symptoms of
• Reduced pain and cramps endometriosis (pelvic pain, irregular
during menses bleeding)
• Reduced pain at time of • Decreased symptoms of polycystic
ovulation ovarian syndrome (irregular bleeding,
acne, excess hair on face or body)
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Adapted from Training Resource Package for Family Planning: [Link]
 COCs and cervical cancer
• Cervical cancer is caused by certain types of human
papillomavirus (HPV).
• Some increase in risk among women with HPV and others who
use COCs more than 5 years.
o Risk of cervical cancer goes back to baseline after 10 years of
non-use
• Cervical cancer rates in women of reproductive age are low. Risk
of cervical cancer at this age group is low compared to mortality
and morbidities associated with pregnancy.

COC users should follow the same cervical cancer

screening schedule as other women.
34
Adapted from Training Resource Package for Family Planning: [Link]
COCs: Risk of blood clots is limited
• COCs may slightly increase risk of blood clots:
– Stroke • Deep vein thrombosis
– Heart attack • Pulmonary embolism

• Risk is concentrated among women who have

additional risk factors, such as:
– Hypertension
– Diabetes
– Smoking

Stop COCs immediately if a blood clot develops.

35
Adapted from Training Resource Package for Family Planning: [Link]
 COTRAINDICATIONS
• ABSOLUTE RELATIVE
• Cancer of breast & age over 40 yrs
genitals smoking
• Thromboembolism age over 35 yrs
• Cardiac abnormilities hypertension
• Congenital hyperlipidemia renal disease
• Undiagnosed AUB MIGRANE
DM,gall bladder dis
ease.
Combined injectable contraceptives
(monthly injectables)

37
 DEPOT FORMULATIONS
• Highly effective,reversible,longacting,oestro—
-- gen free for spacing pregnancies.
1) Injectable contraceptives
2) Subdermal implants
3) Vaginal rings.
 INJECTABLE CONTRACEPTIVES
• A) Progestogen – only- injectables-
a) DMPA(Depot-Medroxyprogesterone
Acetate)
b) NET-EN( Norethiserone enantate)
c) DMPA-SC
 DMPA
• Depo-provera.
• Dose– Intramuscular injection of 150mg every
3 months.
• MOA– supresses the ovulation.
• Advantage– does not affect lactation.
• Side effects– weight increase, irregular
menstrual bleeding and prolonged infertility.
• Multipara of age over 30 years.
 NET--EN
• Norethisterone enantate.(1966)
• Dose—intramuscularly,200mg every 60 days.
• MOA—inhibition of ovulation,progestogenic
effects on cervical mucous.
• 0.4 failure rate.
 ADMINISTRATION
• During first 5 days of menstrual period
• Deep intramuscular injection in gluteus
maximus.
• May be given two weeks early or two weeks
late.
 DMPA—SC 104 mg
• Depo sub Q provera 104.
• Injected under the skin rather muscle.
• Contain 104 mg of DMPA.
• Given at 3 months interval.
• Upper thigh or abdomen
• Contraindications– cancer breast,genital
cancer,undiagnosed AUB,malignancy.,high BP.
 COMBINED INJECTABLES
CONTRACEPTIVES
• Injectables contain progesterone and oestrogen both.
• Given at monthly intervals plus or minus 3 days.
• MOA– supression of ovulation
• Cyclofem/ Cycloprovera,Mesigyna
• 0.2% and 0.4% failure rate.
• Contraindications- suspected
pregnancy ,thromboembolic disorders,CAD,breast
cancer,mi
grane.
 IMPLANTS
 Implants are placed in the body filled with hormone
that prevents pregnancy
 Physically inserted in simple 15 minute outpatient
procedure
 Plastic capsules the size of paper matchsticks
inserted under the skin in the arm
 99.95% effectiveness rate
 Norplant I vs. Norplant II

 Six capsules  Two capsules

 Five years  Three years
Norplant Implant
 35 mg (each) of
Levonorgesterol.
 Norplant Considerations
 Should be considered long term birth control

 Requires no upkeep 
 Extremely effective in pregnancy prevention >
99%
 VAGINAL RINGS
• Vaginal rings containing levonorgesterol .
• The hormone is slowly absorbed through the
vaginal mucosa,permitting most of it to bypass
The digestive system and liver and allowing
potentially lower dose.
• The ring is worn in vagina for 3 weeks of cycle
and removed for the fourth.
 CENTCHROMAN NON HORMONAL PILL
CHHAYA
• Commonly known as weekly pill as for first 3
months ,it is taken biweekly and from 4 th months
onwords,once weekly.
• It can be initiated anytime during the menstrual cycle.
• Timing of initiation---
• On first day of period
• On the day of abortion itself
• Within 4 weeks after childbirth,whether
breastfeeding or not.
 centchroman
• Take one pill at correct time
• Take another pill 3 days later
• Followed for 3 months
• From 4 th month onwords , only one pill to be
taken per week
• Then the weekly regime to be continued.