Contraception

A/Prof Dr Paul Ng Department of Obstetrics and Gynaecology University Kebangsaan Malaysia

Contraception

Contraception
Important that women are able to plan timing of children Aim of contraception is to prevent pregnancies from occurring while causing the least amount of side effects to the patient

Contraception should also be reversible as soon as its use has ended

Modes of action of contraception

Types of contraception
Oral contraception- COCP, progestogen only pill Injectable- provera Implant- Implanon ( historically- Norplant) Intrauterine- IUCD, Mirena IUS Barrier contraception- condoms. Diaphragm Postcoital contraception Natural- rhythm method, coitus interruptus

EFFECTIVENESS
Dependent of motivation, regular usage, correct manner Assessed by Pearl Index
Number of pregnancies which occur in 100 women using that method for a year

Combined Oral contraception

Combined oral contraceptive pill

Contains ethinyl oestradiol and a progestogen Meant to be taken for 21 days with a pillfree week Low dose pills now more commonly usedMercilon, Loette, Yasmin, Diane

COMBINED PILL
Oestrogen + progesterone Inhibit ovulation Not dependent on intercourse Additional advantages Disadvantagecompliance is needed Pearl index 0.1-1.5

COMBINED PILL
Commonest regime
Start on day 1 of a cycle; a pill is taken each day for 21 days; then 7 days pill free

If >35 years and smoking, alternative method is preferred Contraindications

Active liver disease VTE Migraine IHD Vulvular heart disease Pulmonary HT TIA or cerebral haemorrhage

What to do if forgotten to take the pill?

COMBINED PILL
What to do if forgotten to take the pill?
<12 hrs <12 hrs

Take the pill immediately, further pills as usual

Take most recent delayed pill. Discard earlier missed pills Use extra precaution for next 7 days How many more pills left?

7 pills or more

< 7 pills Start the next pack immediately after Finishing with the old pack

When finish, leave the usual 7-day break

Additional benefits of the COCP

Reduces menstrual blood loss by up to 50% Reduces dysmenorrhea May help to improve acne Reduces the lifetime risk of developing ovarian cancer

Progestogen Only Contraception

Progestogen only contraception

Works mainly by causing thickening of the cervical mucus causing a barrier to sperm cells. Lesser effect on ovulation Needs to be taken everyday Must be taken < 3 hours after expected consumption of the pill the following day

PROGESTOGEN ONLY
Continuous daily Pearl index 1.5-3.0 Act by increasing viscosity of cervical mucus Breakthrough bleeding No risk of VTE Can be use during lactation

Depo-provera
Depo-medroxyprogesterone acetate Given as 1 injection every 12 weeks Inhibits ovulation at that dose and after 1 year of usage 80% are either amenorrhoeic or have scanty infrequent periods 20% may still present with irregular bleeding episodes

Side effects
Weight gain A delay in the resumption of fertility can occur for up to 1 year Small reduction in bone density

IM DEPO
Slow-release, long acting Progesterone, intramuscular Interval 1-6 months Depo-provera, norethisterone IM Depo-Provera 150mg 3-monthly-----Pearl index 0.5-1.5 Independent on intercourse / patients memory

SIDE EFFECT OF SYSTEMIC CONTRACEPTIVES

Headache Nausea Facial pigmentation Fluid retention Weight gain Breast tenderness Breakthrough bleeding

IM DEPO
Benefit in
Dysmenorrhoea Menorrhagia Premenstrual symptoms Lactation, no effect on BP / VTE risk of CA endometrium 5-fold

Side effects
Irregular uterine bleed Amenorrhoea Weight gain Delay return in fertility of 6 months

SYSTEMIC CONTRACEPTION--SPECIFIC SITUATIONS Hypertension Metabolic effects Hepatic function Carcinogenic Dysmenorrhoea Lactation Surgery Drug interaction

Intrauterine Devices

Intrauterine Contraceptive Device (IUCD)

Copper containing Effective Effects are by causing a toxic effect to sperm and the egg Can affect fallopian tube motility and is associated with an increased risk of ectopic pregnancy

Intrauterine Contraceptive Device (IUCD)

Has an increased risk of infection associated with the first 3 weeks of insertion Copper IUCD associated with increased menstrual loss Occasionally can have problem of missing strings, lost IUCD that may require investigation or surgical exploration/ removal

Benefits
Does not require a person to take medication Good for those with a contra-indication to taking oestrogen Useful for patients who are not compliant to taking medicines ( but be careful of risk of pelvic infections)

IUD
Insertion-exclude contraindication Renewal 3-5 years Removal by pulling the tail Pearl index <3 Side effects
Pain Menstrual loss Expulsion <3% Uterine perforation 1 in 1000 Salpingitis 1.5-7.5 per 1000 Endometritis

IUCD
Mild inflammatory reaction in endometrium Previously: loop, ring, spiral coil, T, 7 Now:
Multiload, NovaT Copper-inhibit implantation, spermicidal Gynefix Mirena-levonogestrel

Intrauterine System
Mirena
Contained levonogestrel 52mg For 5 years Reduction of menstrual loss by 97% after 12 months Can be used with HRT as endometrial protection

Implants

Implanon
Uses Etonogestrel Lasts up to 3 years

Effective
Irregular bleeding (compare with norplant)

Barrier Methods

CONDOM
Most widely used in UK Simple Should be used with a chemical spermicide added security Pearl index 4-10

CONDOM
Benefit
risk of venereal infection Controlling the spread of HIV

Failure
Defective of the sheath Require emergency contraception

DIAPHRAGM & CAPS

Efficient if used correctly and carefully Spermicidal cream is smeared around the rim Insertion before intercourse Should not be taken out before 6 hours Varies size, chose by the doctor Recheck size after pregnancy

SPERMICIDE
Chemical substance placed in vagina before intercourse Pessaries, creams, aerosol, foaming tablets Poor result when use on their own Side effectsoreness / irritation

Natural Methods

COITUS INTERRUPTUS
Withdrawal of penis before ejaculation Pearl index 20-30 Failure due to
Delay withdrawal Presence of sperm in the pre-ejaculatory fluid

RHYTHM METHOD
Permitted by the Roman Catholic faith Pearl index 20-30 Assumption
The ovum is only capable to be fertilized in 24 hrs Sperm can only fertilize ovum in 72 hours

RHYTHM METHOD
Not suitable for irregular cycles Monitor cycles for 1 year Deduct the shortest cycle with 18 Deduct the longest cycle with 11 Example:
Cycle 26-32 days 26-18=day 8; 32-11=day 21 Day 8-21 will be fertile period

BODY TEMPERATURE
Ovulation -------basal body temperature Avoid intercourse for the next 72 hours Pearl index 5-7

Sterilisation

TUBAL OCCLUSION
Laparotomy / laparoscopy / colpotomy Ligate / diathermies / clip / ring Preferred to be performed 6 weeks postpartum Anaesthetic risk Failure 1-2 in 1000

VASECTOMY
Simpler & safer than tubal occlusion Not immediately effective Complications:
Hematoma infection

LACTATIONAL AMENORRHOEA METHOD (LAM)

Breastfeeding delay return of fertility The delay dependent of frequency & duration of BF episodes Criteria
Fully / near fully BF Amenorrhoeic
Chance of pregnancy within 1st 6 months is <2%

Failure rate 0.5-0.6%

Emergency Contraception

EMERGENCY CONTRACEPTION
Yuzpe regime:
100g EE, 500g levenorgestrel BD Within 72 hours Failure rate 3.2%

Prostinol
750g levonorgestrel BD Failure rate 1.1% Fewer side effects

Copper IUD
Within 5 days Most effective

Conclusion
There are many forms of contraception available Important to know the advantages and disadvantages of these options Useful to see what is being advised for our post-natal patients and relate the types of contraception recommended with each individual patient