Contraception .pptx OBGYN Reproductive health./family planning/family planning methods.

This ppt contains notes on combined oral contraceptives, their side effects, mechanism of action, indications and contraindications of combined oral contraceptives. The notes are under the topic #Reproductive health and family planning. Notes on methods of family planning. Obstetrics and gynecology.

1. CONTRACEPTION AND CHILD SPACING Dr Michieka Nyariki

2. Outline: List contraceptive types Understand Medical Eligibility Criteria for various contraceptives Challenges of contraception

3. Contraceptive types: Natural Vs Artificial methods Hormonal vs non-hormonal Mode of administration: oral, injectables , implants, etc

4. Natural Contraceptive options Fertility awareness-based methods(FAMs). Understanding tracking of ovulation. MOA: Keeping sperm away from reproductive tract during/near ovulation. During this period the couple may enjoy other kinds of sexual activity instead of vaginal intercourse. Other contraceptive options may as-well be temporarily employed eg .. Barriers, spermicides, EP etc

5. FAMs Revision: Period of ovulation Signs of ovulation

6. FAMs Success depends on accuracy and consistency. 95-98% effective with perfect use 75-88% for typical use

7. FAMs: Benefits Effective No side effects, no hormonal exposure Promotes positive body awareness Consistent with many religeous beliefs Fosters communication among partners Encourages enjoying sexual activities variably Encourages male involvement

8. FAMs: Disadvantages No protection from STD/STI Difficult to find trained FAM/NFP instructors Requires time to learn: 3-6 cycles Requires discipline and commitment Times of abstinence may be a challenge to some couples

9. NFP/FAM methods Abstinence Coitus interruptus Lactational Amenorrhea Method(LAM) Temperature method Rhythm/Calendar method Withdrawal method “?? Komo nyuol ”

10. Hormonal Contraceptives: Combined hormonal Contraceptives(CHCs) Progestin only contraceptives Administration: Oral, Implants, Injections, Skin patches, Vaginal rings

11. Combined Hormonal Contraceptives Combined Oral Contraceptive(COC) Combined Injectable Contraceptive(CIC) Combined Contraceptive Patch(CCP) Combined Contraceptive Vaginal Ring(CVR)

12. CHCs: COC Low dose COC: Contain less than 35mcg ethinyl estradion , combined with a progestogen . Progestogens : norethisterone , norgestimate , etc Taken daily. Brainstorm on C/I, Complications, Special circumstances.

13. Selection of the patient Hx and P.E should be thorough, screen for contraindications. Breast exam-nodules, weight and BP Pelvic exam-exclude cervical pathology/cervical cytology Exclude pregnancy Follow up @ 3/12 then 6/12 then yrly . If > 35,checked more frequently. MEC for contraceptive use

14. COC: Administration Ideally begin from 1st day of menstrual cycle, no back up contraception is needed ‘Sunday start’, back up method used for one week. ‘Quick start’, back up method used for one week. For max. efficiency pills should be taken same time each day Simple regime ‘3weeks on and 1 week off’ Failure rate 0.1 per 100 women year

15. CHCs: CIC Brand names: Cyclofem , Novafem , Mesigyna , Lunelle , cyclo-provera Prevents ovulation, thickens cervical mucus, +Endometrial changes Administered IM monthly(28-30 days), effective up to 33 days SE: Menstrual irregularities during initial 3-6 months

16. CHCs:CCP Transdermal patch, changed weekly. Patch change day: 1 st day of menses then weekly there after, or 1 st Sunday following onset of menses. After 3 patches, skip for menses. Patch locations: clean+ intact skin: Upper outer arm, buttocks, abdomen or thigh. Easy application …... ? O ther advantages: brainstorm

17. CHCs: CCP. Initiate first day of cycle, weekly for 3/52 followed by a patch free week to allow withdrawal bleeding. Application site reaction and breast tenderness frequent in initial wearers Obesity >/= 90kg may be associated with increased risk of patch failure. ?Higher risks of VTE than COCs

18. CHCs: CVR Examples of vaginal rings: Estring , Femring , NuvaRing , Progering . Nuvaring changed 3-weekly, the rest, 3-monthly. Failure rate: 0.3% with perfect use, and 9% with typical use.

19. Drug interactions Drugs that may reduce COC efficacy ; Rifampicin,griseofulvin . Anticonvulsants;phenytion,phenobarbital,primidone,ethosuxide,CBZ Antibiotics;Tetracycline,penicililins,ciprofloxacin,ofloxacin Antiretrovirals .

20. Drugs whose efficacy is reduced by COCs ; Analgesics;acetaminophen,aspirin Anticoagulants;Dicumarol,wafarin Antidepressants;imipramine Tranquillizers;diazepam Anti-inflammatories;corticosteroids Bronchodilators Antihypertensives;metoprolol

21. Non contraceptive benefits Increased bone density Reduced menstrual blood loss and anemia Decreased risk of ectopic pregnancy improved dysmenorrhea from endometriosis Decreased risk of endometrial and ovarian ca Reduction in various benign breast diseases Inhibition of hirsuitism progression Improvemnet of acne Prevention of atherogenesis Decreased Ac of R.A Decreased incidence and severity of acute salpingitis

22. Cardiovascular effects Thromboembolic disease M.I Stroke Factors that increase risk of VTE with COC use: HPTN, obesity, diabetes, smoking , sedentary lifestyle, >35yrs Decreased rates with lower dose formulations containing 20-25ug ethinylestradiol . Rarely cause clinically significant HPTN

23. Any Questions?

24. Progestin Only Contraceptives(POC): Progestin Only Pill(POP): minipill / microlut Progestin Injectable Contraceptive: Depot medroxyprogesterone acetate(DMPA), Norethisterone enanthate (NET-EN). Progestin(hormonal) IUD: Levonogestrel : Mirena , Skyla Implants: etonogestrel : Implanon , Jadelle , Norplant

25. POC: MOA Prevent full development of ovum + prevent ovulation in 60% Cervical changes: thickening of cervical mucus Endometrial changes: thinning

26. POP: Demerits m ust be taken same time everyday. If taken even 4hours late, back up form of contraceptive must be used in the next 48 hrs Higher rates of functional ovarian cysts Irregular uterine bleeding : amenorrhea, menorrhagia, metrorrhagia Contraindicated in women with unexplained uterine bleeding, known breast ca , benign/malignant liver tumors.

27. Brainstorm: Timing of initiation of POC SE of POC Myths and Facts

28. Emergency contraception/ postcoital contraception Hormones Anti progesterone IUD Others Unprotected sex, condom rupture, missed pill, sexual assault/rape Risk of pregnancy following a single act of unprotected coitus around time of ovulation is 8%.

29. EC No fetal adverse effects has been observed where there is failure of emergency contraception. Ovulation is prevented or delayed when drug is taken in the beginning of the cycle. Fertilization is interfered with. Implantation is interfered with Interferes with the function of corpus luteum and may cause luteolysis .

30. Non-Hormonal Contraceptives: Barriers: physical barriers IUCD Spermicides/foams: chemical barriers Natural methods: already discussed Permanent methods: vasectomy, tubal ligation

31. Barriers: Male condom Female condom Diaphragm/cervical cap Sponges

32. IUCD: Copper T380A T-shaped. Two monofilament strings attached to vertical arm to ascertain uterine placement Lifespan 10yrs Proposed MOAs – Spermicidal activity, interference with ova fertilization, impede sperm migration, impair implantation Pg rate 0.6 pgs/100 woman-years

33. Risks - PID around the time of insertion, increased risk of ectopic pg IF FERTILIZATION OCCURS WITH IUCD IN SITU, spont abortions, uterine perforation and iucd expulsion. If one gets pregnant with iucd in-situ, risk of spontaneous abortion, PROM and preterm labour Not to be used in advanced HIV disease Minor S/E – cramping and abnormal bleeding

34. READING Male and female sterilization Assure?

35. GRACIAS