Physiology of the menstral cycle and Natural Family Planning Methods

NATURAL FAMILY PLANNING METHODS

1. Group 3 Presentation Facilitator –Prof. Omondi Ogutu Group Members: Dr. Sarah Kamau-HOG6/44107/2023 Dr. Robert Maina - H58/43067/2022 Dr. Yvonne Mukiri-HOG6/44724/2023 Dr. Mandeq Adow Mohammed-H58/43584/2022 Dr. Faith Mwikali Vuku - H58/43237/2022 PHYSIOLOGY OF THE MENSTRUAL CYCLE AND NATURAL FAMILY PLANNING METHODS(NFP)

2. Outline Introduction Physiology of menstrual cycle Types of NFP Mode of action Indications Side effects Special considerations(HIV, Cardiac disease) Emerging issues

3. Natural Family Planning Methods These are Fertility-awareness methods based on: Fertile window Cycle length Cervical secretions Basal body temperature Methods rely on: The periodicity of fertility and infertility A single ovulation each cycle Limited duration of viability of the ovum, which is 12 to 24 hours after its release The limited duration of viability of sperm-3 to 5 days in cervical mucus and the upper genital tract A woman’s ability to monitor cycle length and cycle-related symptoms and signs such as cervical mucus It is important to have an understanding of the normal menstrual cycle in order to understand how these methods work.

4. The Menstrual Cycle The normal menstrual cycle is a tightly coordinated cycle of stimulatory and inhibitory effects that results in the release of a single mature oocyte from a pool of hundreds of thousands of primordial oocytes. Menstruation is the visible manifestation of cyclic physiologic uterine bleeding due to shedding of the endometrium following invisible interplay of hormones mainly through the hypothalamo -pituitary-ovarian axis.

5. The Menstrual Cycle It is the period extending from the beginning of a period to the beginning of the next one. Menstrual cycle: 21-35 days with a mean of 28 days. Duration: 4-8 days Estimated blood loss: 20-80ml with an average of 35mls. Nearly 70% of total blood loss occurs in the first 2 days. .

6. Ovarian Cycle These ovarian changes constitute the: (1) The follicular phase (day 1 to 13),  (2) Ovulatory phase (day 13 to 15) (3) The luteal phase (day 15 to 28). The luteal phase is always constant 14 days(secretory phase)

7. Follicular phase Constitutes the development and maturation of a follicle,ovulation,formation of corpus luteum Consists of :  Recruitment of groups of follicles Selection of dominant follicle and its maturation Ovulation Corpus luteum formation

8. Follicular Phase Recruitment of groups of follicles-(5 to 20 preantral ) Initial recruitment and growth of primordial follicles are not under the control of any hormone. FSH(due to low estrogen and progesterone) needed for eventual maturation Granulosa cells develop FSH receptors Selection of dominant follicle(day 5-7) and its maturation Follicle with highest antral concentration of estrogen and low androgens and highest FSH receptors Enlargement of granulosa cells with lipid inclusion FSH induces LH receptors Theca cells become more vascular than those of other antral follicles.. Separated from granulosa cells by membrana granulosa The fully matured Graafian follicle measures about 20mm.

9. Ovarian Cycle Ovulation Dominant follicle reaches surface of ovary shortly before ovulation Serum estradiol levels continue to rise reaching a peak a day prior to ovulation which then precipitates the LH surge Cumulus detaches from wall of follicle Stigma develops and penetrates the outer surface layer of ovary. Oocyte oozes out with corona radiata which takes about 60-120secs The oocyte completes its 1 st meiotic division. It is released from the surface of the ovary approximately 36hours after the LH surge. There is a close relation of follicular rupture and oocyte release to the LH surge; as a result, measurements of serum or urine LH can be used to estimate the time of ovulation.

10. Corpus luteum formation Ruptured graffian follicle develops into corpus luteum and undergoes four stages of development(under the influence of LH) Proliferation: granulosa cells undergo hypertrophy, become lipid filled Vascularization: capillaries grow into granulosa layer, within 24hrs of rupture of follicle. Maturation: attains full size of 1-2cm, approximately 7-8 days following ovulation.theca interna cells become hypertrophied. Regression:  starts on 22-23 rd day of cycle if fertilization doesn’t occur. Life span is about 12-14 days.If fertilization occurs,its converted into corpus luteum of pregnancy. Main function of CL is production of progesterone and estrogen

11. Ovarian Cycle  

12. Hormonal changes during the menstrual cycle

13. Endometrial Cycle The endometrium consist of surface epithelium, glands, stroma and blood vessels. It has two distinct divisions: Basal zone 1/3 rd of the total depth Lies in contact with the myometrium Uninfluenced by hormones and as such no cyclic changes are observed Measures about 1mm Functional zone Under the influence of fluctuating cyclic ovarian hormones Estrogen Progesterone Undergoes 4 phases

14. Regeneration Phase Starts even before menstruation ceases Ends 2-3 days after menstruation ceases Vessels grow from stumps in the basal zone Stroma and glands regenerate from remnants in the basal zone Thickness averages 2mm Glands are lined by cuboidal epithelium and lie parallel to the surface

15. Proliferative Phase Extends from 5 th or 6 th day to 14 th day (till ovulation) Glands become tubular, lie perpendicular to the surface  The epithelium becomes columnar The epithelium of one gland becomes continuous with the neighbouring gland. Stromal cells become spindled shaped with evidence of mitosis Spiral vessels extend unbranched to a region below the epithelium where they form loose capillary networks Thickness measures 10-12mm at time of ovulation

16. Secretory Phase Begins day 15 and ceases 5-6 days prior to menstruation Endometrium has receptors for progesterone which are primed by estrogen Blood vessels undergo marked spiraling Glands become engorged, cock screw shaped and secrete nutritive fluids Stromal cells become swollen and large Vacuoles appear due to secretion of glycogen between the nuclei and the basement membrane Endometrial growth ceases 5-6days prior to menstruation due to dehydration of the glands

17. Menstrual Phase Regeneration of corpus luteum leads to regression of estrogen and progesterone levels Stasis of blood and spasms lead to damage of arteriolar walls Auto-digestion by proteolytic enzymes Leukocyte and monocyte invasion occurs Bleeding from damaged arteries, veins and capillaries and stromal hematoma Coagulated blood in uterine cavity broken down by plasmin enabling it to flow Endometrial flow stops due to prolonged vasoconstriction, myometrial contraction, platelet aggregation Return of oestrogen secretion facilitates clot formation at blood vessel stumps Prostaglandins aid in arteriolar constriction and myometrial contraction

18. Cervical Cycle Progesterone rises the tone of the muscles of the isthmus and internal os so the cervical ‘sphincter’ is tighter and more competent during the luteal than follicular phase The glandular elements proliferate during the follicular phase and the epithelial cells become taller and secrete a mucus which will stretch into threads During the follicular phase the cervical mucus absorbs water and salts and when allowed to dry, deposits crystals of sodium chloride and potassium chloride in a characteristic fern pattern

19. Cervical Cycle The cervical mucus is so profuse at the time of ovulation that it may be noticed as a vaginal discharge Its special character at this time, (low protein content) makes it easy for spermatozoa penetration During luteal phase, cervical glands become more branched, and their secretion becomes mores viscous forming a secure cervical plug.

20. Cervical Cycle Cervical Characteristics Follicular Phase Luteal Phase Internal os Funnel- shaped Tightly closed Mucus Thin and watery Thin and viscid Stretchability Increased to beyond 10cm lost Fern tree pattern present lost Glycoprotein network Parallel, thus facilitating sperm penetration Interlacing bridges, preventing sperm penetration Glandular epithelium Taller Glands-more branched

21. Fallopian Tube Cycle The muscle of the fallopian tube behaves like the myometrium at the time of ovulation. This is an estrogen effect The follicular phase is marked by slight proliferation, and continuing to premenstrual phase then regresses During menstruation there is further shrinkage and slight shedding of the surface epithelium. The secretory activity of the tubes is also cyclical, being highest before ovulation and in response to oestrogen.

22. Vaginal Cycle The fully oestrogenic smear, evident during the late follicular phase, contains a preponderance of large cornified epithelial cells with pyknotic (condensed) nuclei. These stain pink with eosin.  During the luteal phase the smear shows evidence of increased desquamation, many of the cells having rolled edges, and is characterized by the reappearance of clumps of intermediate cells and the presence of leucocytes. The maturation index, which is the percentage of superficial, intermediate and parabasal cells in a vaginal smear is used as a measure of the levels of hormones in circulation. It is a useful guide but is not so precise as assaying the estrogen in blood.

23. Vaginal discharge At the very end of the period Brownish discharge(old blood) signifying the end of the period Days immediately after the period Dry days-little to no discharge Days approaching ovulation Before an ovum is released, upto 30 times more mucus is produced than after ovulation. It is more watery and elastic and may be cream-like in appearance Ovulation The discharge is highest in the days surrounding ovulation , has an ‘egg-white’ appearance and is stretchy( Spinnbarkeit ) Days after ovulation and before menstruation Less discharge may be present and may have a thicker consistency

24. Natural Family Planning Methods include: Standard days method Cervical mucus or ovulation method Multimodal methods Lactational amenorrhoea Basal body temperature trackers

25. Standard days method Is a calendar-based method that is based on the possibility of pregnancy relative to the day of ovulation and the probability of ovulation occurring at around mid-cycle. Abstinence or barrier methods are to be used from day 8 to day 19 of the menstrual cycle Is suitable for women with regular 26 to 32 day cycles Not suitable for individuals with polycystic ovary syndrome, adolescents whose cycles may be irregular in early post menarche, breastfeeding persons with amenorrhea, individuals who have recently been pregnant, and those in the menopausal transition . Tracking aids such as cycle beads or mobile phone applications are useful for teaching couples, for visual representation of day 8 to 19 to enhance adherence and for monitoring cycle length.

26. Cycle beads

27. Cycle beads

28. Cervical mucus or ovulation method Requires individuals to evaluate their cervical secretions several times each day to decide whether the day is a potentially fertile day Suitable for persons with cycles <26 or >32 days Examples include: two day method, Billing’s ovulation and Creighton Model method

29. Two day method This method requires the woman to assess for presence or absence of cervical secretions to determine the fertile period. TwoDay Method users are counseled to avoid unprotected intercourse on all days that they note the presence of secretions and on the first day following a day with secretions. The presence of secretions corresponds to the actual fertile window. No further examination of the characteristics of the secretions is necessary. This concept is based on: no secretions immediately following menses, secretions beginning a few days after menses and continuing for several days, and absence of secretions again until after the next menses.

30. Two-day method

31. Billing’s method Also called the cervical mucus method and the ovulation method. Developed in Australia in the 1950s by Dr. John and Evelyn Billings. This method involves observing and tracking changes in cervical mucus and using this information to pinpoint ovulation Women track and record their cervical secretions taking note of colour, elasticity, abundance and viscosity. Techniques include touching the vulva with the fingers or toilet paper to collect secretions and assess their characteristics, noting secretions on underwear, and simply "feeling" wetness at the vulva. Users of this method are advised to advise unprotected intercourse: During menses because of the possibility that menstrual bleeding could obscure the presence of secretions, particularly in short cycles •On preovulatory days following days with intercourse even if there are no secretions present because of the possible confusion with semen •On all days with wet, slippery, transparent, or stretchy secretions consistent with ovulation •Until four days past the last day with wet secretions The number of days of abstinence or use of barrier methods is 14-17days when this method is used.

32. Creighton Model-Background As ovulation approaches, the stretchability and clarity of the mucus increased along with its quantity of production. At the same time, the viscosity and its content of leukocytes decreased. The most pertinent observation, however, was the indication that the survival of the spermatozoa was directly related to the presence or the absence of an ovulatory or periovulatory type of mucus produced from the cervix. External observations of cervical mucus are used to obtain pertinent information on the phases of fertility and infertility and the state of the woman’s procreative and gynecologic health. The Creighton model can be used any time during a woman’s reproductive life and is effective even with irregular cycles, during breastfeeding and the perimenopause .

33. stcatherinefertilitycare.com

34. Symptothermal method A combination of the cervical mucus method, calendar method and the basal body temperature method. The first day of the fertile period is determined either by the calendar method or the cervical mucus method The end of the fertile period is determined by a rise in BBT by 0.2-0.5 C Intercourse can resume 3 days after the rise in basal body temperature

35. Possibility of conception from intercourse on days relative to ovulation

36. Coitus interruptus Is the oldest contraceptive method Results in deposition of semen outside the female genital tract The man is required to have sufficient self-control so that withdrawal precedes ejaculation Benefits No cost No medical assistance required Disadvantages Requires sufficient self control by the man The woman may develop anxiety neurosis, vaginismus or pelvic congestion High failure rates due to presence of sperm in pre-ejaculation secretions and delay in withdrawal

37. Lactational Amenorrhoea Method(LAM) Amenorrhea during breastfeeding may be related, in part, to higher prolactin levels compared with individuals who become ovulatory while breastfeeding, since prolactin inhibits pulsatile GnRH release from the hypothalamus It is thought that infant suckling results in a reduction of pulsatile secretion of gonadotropin-releasing hormone ( GnRH ) and luteinizing hormone (LH), which in turn suppresses ovarian activity. During exclusive breastfeeding, approximately 40 percent of individuals will remain amenorrheic at six months postpartum. Pregnancy rates for LAM range from 4.5 to 75 unintended pregnancies per 1000 women exclusively using this method. The woman should transition to other contraceptive methods as soon as supplemental feeding or menstruation starts, or once the baby is older than six months.

38. LAM Efficacy Failure rate within the first 6 months in a woman who is exclusively breastfeeding and is amenorrhoeic is 2% Advantages The woman has complete control There is no requirement for exogenous contraceptive methods Disadvantages Return of fertility is uncertain Pregnancy may occur during the period of amenorrhoea

39. Historical Methods Calendar Rhythm Determine length of last 6 cycles Subtract 18 from the shortest cycle and 11 from the number of days in the longest cycle to determine the fertile period. For example if the shortest cycle was 26days long and the longest 32 days, the fertile period is from day 8 to day 21 of each cycle Resulted in high failure rates due to prolonged periods of monitoring cycle length prior to its use and involved arithmetic calculations.

40. Historical Methods Basal Body Temperature (BBT) BBT elevation signifies the end rather than the beginning of the fertile period Users therefore have to avoid unprotected intercourse until the fertile period is over(at least 3 days of elevated BBT), which is more than half the cycle.

41. NFP-Advantages Methods are inexpensive(require only charts which may be home-made) There are no physical side effects Control is in the woman’s or couple’s hands Encourages partner participation Increases knowledge of the reproductive system Can be used both to achieve and avoid pregnancy Acceptable for clients who consider it religiously unacceptable to use pharmacological or modern methods

42. NFP-Disadvantages Keeping accurate records of cycle length for prolonged periods is difficult The need for perseverance and correct interpretation of the charts The possible need for medical advice and assistance Possibility of alteration of a woman’s cycle with change in factors such as nutritional status and strenuous exercise routines High failure rates of up to 25% FAB methods do not protect against STIs

43. NFP- Relative contraindications Irregular cycles-women with irregular cycles including those with recent menarche, perimenopause and oligo-ovualtion may be sub-optimal candidates as the success of these methods is largely dependent on identification of the fertile window. Interruption of cycles following pregnancy or pregnancy loss prior to the return of regular cycles Inability to track physiologic changes e.g. adolescents, women with intellectual disabilities and those in unstable environments Lack of a supportive partner-the use of FAB methods require periodic abstinence or use of barrier methods.

44. Women and couples with HIV Contraception is a vital component of medical care for women with HIV or at high risk of acquiring HIV. Fertility awareness based methods can be used without restriction Condom use is encouraged to prevent HIV transmission More effective methods may be used where the couple does not desire more children.

45. Contraception in women with cardiac disease Choice of contraceptive method depends on the pregnancy risk by cardiac condition as shown below.

46. Contraception in women with cardiac disease Recommended methods Progesterone only pills-MEC 2 Implants-MEC 2 Levonorgestrel IUD- MEC 2 Copper IUD-MEC 1 Bilateral tubal ligation Ideally multidisciplinary team-based counseling and contraceptive management should be developed for women at increased risk of cardiovascular or fetal complications of pregnancy. A place for NFP has not been well defined.

47. Emerging Issues The exponential growth and popularity of computer and smartphone applications (apps) related to fertility suggest that clinicians should be prepared to guide their patients in identifying and selecting apps that provide accurate information and are appropriate for particular needs. Caution must however be exercised as a majority of these apps are not based on evidence-based FAB methods. Objective evaluation of an app is required prior to recommending its use to a patient to avoid errors and litigation. Of the newer technologies, urinary hormone monitoring is emerging as a proven approach with several options available today or in development. Daily, at-home monitoring of urinary metabolites of estrogen and LH is available today.

48. References Dutta’s Textbook of Gynaecology, 6 th edition Basic science in obstetrics and gynaecology https://www.uptodate.com/contents/fertility-awareness-based-methods-of-pregnancy-prevention/contributors Lactational amenorrhoea method for family planning. AU Van der Wijden C, Manion C  SO Cochrane Database Syst Rev. 2015;  Dynamics of follicular growth in the human: a model from preliminary results. AU Gougeon A  SO Hum Reprod . 1986;1(2):81.  Frequency modulation of follicle-stimulating hormone (FSH) during the luteal-follicular transition: evidence for FSH control of inhibin B in normal women. AU Welt CK, Martin KA, Taylor AE, Lambert- Messerlian GM, Crowley WF Jr , Smith JA, Schoenfeld DA, Hall JE  SO J Clin Endocrinol Metab . 1997;82(8):2645. The State of the Science of Natural Family Planning Fifty Years after Humane Vitae : A Report from NFP Scientists’ Meeting Held at the US Conference of Catholic Bishops, April 4, 2018 Michael D. Manhart , PhD 1 and Richard J. Fehring , PhD, RN, FAAN 2