TEMPORARY CONTRACEPTION choice, methods.pptx

TEMPORARY CONTRACEPTION choice, methods.pptx

1. TEMPORARY CONTRACEPTION

2. DEFINITION OF CONTRACEPTION A method or a system which allows intercourse and yet prevents conception is called a contraceptive method

3. TEMPORARY CONTRACEPTION The contraception may be temporary when the effect of preventing pregnancy lasts while the couple uses the method but the fertility returns immediately or within a few months of its discontinuation.

4. CHOICE OF CONTRACEPTION Availability cost Age and parity of the couple. Reliability (failure rate). Side effects, contraindications to a particular method. Requirement of follow-up. Counselling and allowing the couple to make a suitable choice. The couple may need to change one contraception to another from time to time during the reproductive period. Personal, medical and social factors should be taken into consideration during counselling.

5. METHODS OF TEMPORARY CONTRACEPTION 1. Natural methods: Abstinence during the fertile phase. Withdrawal (coitus interruptus). Breastfeeding. 2. Barrier contraceptives: Use of condoms by male. Use of spermicidal agents. Use of diaphragm, or the cervical cap in the vagina, use of female condom. Use of hormones which alter the cervical mucus and prevent entry of sperms into the cervical canal.

6. 3. Intrauterine contraceptive devices (IUCDs). 4. Suppression of spermatogenesis. 5. Suppression of ovulation with hormones—hormonal contraceptives. 6. Interceptive agents (postcoital contraception). 7. Immunological methods. #Surgical method is the only permanent contraceptive method.

7. 1. NATURAL METHODS Abstinence during the Fertile Phase The woman understands about her fertile period within her menstrual cycle. Four methods- 1.Calender method or rhythm method 2. Mucus method ( Billings or ovulation method) 3. Temperature Method 4. Symptothermal Method

8. Calendar Method Avoidance of sexual intercourse during ovulation. The safe period is, therefore, calculated from the first day of the menstrual period until the 10th day of the cycle and from the 18th to the 28th day. In Knaus –Ogino method, the fertile period is determined by subtracting 18 days from the shortest cycle and 10 days from the longest cycle which gives the first and the last day of fertile period, respectively. Irregular ovulation and irregular menstrual cycles may lead to FAILURE.

9. Mucus Method The properties of the cervical mucus change under the influence of the ovarian hormones on different days of the menstrual cycle. The woman attempts to predict the fertile period by feeling the cervical mucus. Under oestrogen influence, the mucus increases in quantity and becomes progressively more slippery and elastic until a peak is reached. Thereafter, the mucus becomes thicker, scanty and dry under the influence of progesterone until the onset of menses. Intercourse is considered safe during the ‘dry days’ immediately after the menses until mucus is detected. Thereafter, the couple must abstain until the fourth day after the ‘peak day’

10. Temperature Method Progesterone is known to exert a thermogenic effect on the body. Therefore, if the woman records her basal body temperature (BBT) daily on awakening in the morning and plots the readings graphically, the BBT chart will be biphasic in an ovulatory cycle The day of temperature shift indicates the time of ovulation. Difficult method, Hardly practiced

11. Symptothermal Method The first day of abstinence is predicted either from the calendar, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months, or the first day mucus is detected, whichever comes first. The end of the fertile period is predicted by use of the ‘BBT’ chart. The woman resumes intercourse 3 days after the thermal shift. This combination method is more effective Apart from the long periods of abstinence required, this method is not reliable if the woman is lactating or has irregular cycles or develops fever

12. WITHDRAWAL METHOD (coitus interruptus) Coitus takes place in a normal manner but the penis is withdrawn immediately before ejaculation. Advantages of fertility awareness methods are: ( i ) no cost, (ii) no contraindications, (iii) no systemic side effects and (iv) no effect on lactation. Disadvantages are: ( i ) failure rate is high, (ii) requires motivation and (iii) no protection against HIV and STD.

13. BREASTFEEDING Regular breastfeeding with at least one feed at night is shown to prevent pregnancy for 6 months, This occurs due to prolactin preventing LH surge and ovulation. Beyond 6 months of breastfeeding, prolactin level falls and ovulation can occur. It is the frequency rather than the duration of feed that decides nonovulation in a nursing mother.

14. 2. BARRIER METHODS CONDOMS In this method, the erectile penis is completely covered by a very thin rubber (condom) which is used only once. It is desirable to use a condom with a water-based spermicidal agent to improve the efficacy of the method The condoms prevent sexually transmitted diseases (STD) and HIV, but are less protective against STD transmitted from skin-to-skin contact such as human papilloma virus and herpes virus.

15. ADVANTAGES. 1)It is easily available, cheap, easy to carry, free from side effects and requires no instruction. 2)It emphasizes the male involvement in contraceptive effort and is immediately effective. 3)It prevents sperm allergy. 4)It has no adverse effect on pregnancy, should the method fail. 5) Condoms also prevent transmission of STDs from one partner to the other. DISADVANTAGES.1) The method is only partially reliable. 2)vaginal irritation to the latex. 3)full sexual satisfaction.

16. SPERMICIDAL AGENTS The spermicidal agents kill the sperms before the latter gain access to the cervical canal. These chemical contraceptive agents contain surfactants, such as nonoxynol-9, octoxynol and menfegol and enzyme-inhibiting agents, and are available as foam tablets, soluble pessaries, creams, jellies, or as films along with other contraceptives The spermicidal agent remains effective for 1–2 h after the application. By causing irritation and abrasions in chronic use, they can cause vaginal ulceration and perhaps increase the risk of HIV spread rather than prevent it.

17. OCCLUSIVE DIAPHRAGM These provide a barrier in the vagina against direct insemination. The diaphragm is effective when used in conjunction with a chemical spermicide in the form of a jelly or cream, and when sufficient time is allowed for complete destruction of the sperms before the diaphragm is removed. In practice, the diaphragm liberally covered with spermicide can be inserted at any convenient time and is left in position for a minimum of 8 h after coitus. Types:- 1)Dutch cap or Diaphragm 2)Cervical Cap 3)Dumas Cap 4) Femsheild 5)Today Advantages 1)Instant infertility n Reversible in 2–4 months 2) No toxicity 3) No decreased libido 4) cheap and easy to use. Disadvantage 1)Scrotal swelling is sometimes reported.

18. 3.INTRAUTERINE CONTRACEPTIVE DEVICES IUCD is an effective, reversible and long-term method of contraception, which does not require replacement for long periods and does not interfere with sexual activity. Classification of IUCDs Copper carrying devices Progestasert and Levonova

19. Copper carrying devices These devices are Copper T 200, Copper 7, Multiload Copper 250, Copper T 380, Copper T 220 and Nova T. The copper devices are more expensive than inert devices but are reported to exert a better contraceptive effect, with fewer side effects. They have an effective life of about 3–5 years. In these, copper wire of surface area 200 to 250 mm is wrapped round the vertical stem of a polypropylene frame.

20. Progestasert and levonova Progestasert is a T-shaped device carrying 38 mg of progesterone in silicon oil reservoir in the vertical stem. It releases 65 mcg of the hormone per day. The hormone released in the uterus forms a thick plug of mucus at the cervical os which prevents penetration by the sperms and thus exerts an added contraceptive effect. Menstrual problems like menorrhagia and dysmenorrhoea noticed with Copper T are less with this device (40% reduction). It is expensive and requires yearly replacement. levonova , contains 60 mg of levonorgestrel (LNG) and releases the hormone in very low doses (20 mcg/day). It is thus longer acting (5 years) and has a low pregnancy rate. It can be safely recommended for nursing mothers.

21. PATIENT SELECTION Low risk of STD Multiparous woman Monogamous relationship Desirous of long-term reversible method of contraception, but not yet desirous of permanent sterilization Unhappy or unreliable users of oral contraception or barrier contraception

22. USES OF IUCD As a contraceptive Postcoital contraception (emergency contraception) Following excision of uterine septum, Asherman syndrome Hormonal IUCD (Mirena) in menorrhagia and dysmenorrhoea, and hormonal replacement therapy in menopausal women In a woman on tamoxifen for breast cancer, MIRENA can be used to counteract endometrial hyperplasia

23. contraindications Suspected pregnancy Pelvic inflammatory disease (PID), lower genital tract infection Presence of fibroids—because of misfit Menorrhagia and dysmenorrhoea, if Copper T is used Severe anaemia n Diabetic women who are not well controlled—because of slight increase in pelvic infection Heart disease—risk of infection Previous ectopic pregnancy Scarred uterus Preferably avoid its use in unmarried and nulliparous patients because of the risk of PID and subsequent tubal infertility LNG IUCD in breast cancer Abnormally shaped uterus, septate uterus

24. METHODS OF INSERTION PUSH IN TECHNIQUE The vagina and cervix are inspected by means of a speculum. Any vaginal or cervical infection must be treated and cured before a device is inserted. The cervix is grasped with a vulsellum or Allis forceps. The device with the introducer is available in a presterilized pack. The device is mounted into the introducer, and the stop on the introducer is adjusted to the length of the uterine cavity. The introducer is then passed through the cervical canal and the plunger is pressed home. This is known as ‘push-in technique’.

25. PUSH IN TECHNIQUE

26. WITHDRAWAL TECHNIQUE The better method is ‘withdrawal technique’ with less chance of uterine perforation. In this, the rod containing IUCD is inserted up to the fundus. The outer rod is withdrawn followed by inner rod (multiload). The device uncoils within the uterine cavity. The nylon thread is cut to the required length. The forceps and the speculum are removed and the patient is then instructed to examine herself and feel for the thread every week.

27. WITHDRAWAL TECHNIQUE

28. Mechanism of Action. The presence of a foreign body in the uterine cavity renders the migration of spermatozoa difficult. A foreign body within the uterus provokes uterine contractility through prostaglandin release and increases the tubal peristalsis so that the fertilized egg is propelled down the fallopian tube more rapidly than in normal and it reaches the uterine cavity before the development of chorionic villi and thus is unable to implant. The device in situ causes leucocytic infiltration in the endometrium. The macrophages engulf the fertilized egg if it enters the endometrial tissue. Copper T elutes copper which brings about certain enzymatic and metabolic changes in the endometrial tissue which are inimical to the implantation of the fertilized ovum. Progestogen-carrying device causes alteration in the cervical mucus which prevents penetration of sperm, in addition to its local action. It also causes endometrial atrophy.

29. COMPLICATIONS Immediate Difficulty in insertion Vasovagal attack Uterine cramps Early Expulsion (2–5%) Perforation (1–2%) Spotting, menorrhagia (2–10%) Dysmenorrhoea (2–10%) Vaginal infection n Actinomycosis Late PID—2–5%. IUCD does not prevent transmission of HIV Pregnancy—1–3 per 100 woman years (failure rate) Ectopic pregnancy Perforation Menorrhagia Dysmenorrhoe

30. MISPLACED IUCD It is defined as the condition when the tail of the IUCD is not seen through the os . A plain radiograph or pelvic ultrasound will show whether the IUCD is still inside or has been expelled. The causes are: ( i ) uterus has enlarged through pregnancy, (ii) thread has curled inside the uterus, (iii) perforation has occurred or the IUCD is buried in the myometrium (iv) it has been expelled

31. ADVANTAGES DISADVANTAGES It is coital-independent A medical or paramedical personnel is required to screen and insert an IUCD. One-time insertion gives continuous protection for a long period Certain complications have been mentioned. It is cost effective. It is highly effective, newer IUCDs being as effective as oral contraceptives There is no evidence of reduced fertility following its removal. There are no systemic ill effects, unlike oral contraceptives.

32. 4.SUPPRESSION OF SPERMATOGENESIS GLOSSYPOL It is administered orally 10–20 mg daily for 3 months and thereafter 20 mg twice weekly. The action is directly on the seminiferous tubules inhibiting spermatogenesis without altering FSH and LH levels. The side effects such as weakness, hypokalaemia and permanent sterility in 20% cases limit its use.

33. TESTOSTERONE ENANTHATE Testosterone enanthate 200 mg injection weekly causes azoospermia in 6–12 months. Instead of weekly injection, testosterone decanoate 1000 mg IM followed by 500 mg 4-weekly is more convenient. Side effects—osteopenia, liver and lipid metabolism dysfunction, prostate enlargement.

34. GnRH The continuous administration of analogues of gonadotropin-releasing hormone (GnRH) causes a fall in the sperm count and sperm motility. The level of testosterone also falls. The loss of libido and osteoporosis makes this regime unacceptable over a long period. Besides, it is very expensive and needs to be given subcutaneously #Other anti spermatogenic agents are Medroxyprogesterone Acetate and Desogestrel . # The hormonal suppression of spermatogenesis causes loss of libido and is toxic in high doses. #Besides, the injection of hormones is inconvenient to administer regularly. # The acne, weight gain and decreased HDL are other side effects.

35. 5. Suppression of Ovulation (Hormonal Contraceptive Agents)

36. Combined pill Combined oral pills contain a mixture of ethinyloestradiol (EE2) in a dose of 20–30 mcg and an orally active progestogen. MALA-N(21 TAB ) & MALA-D(28 TAB-7 FERROUS FUMARATE) The tablets are taken starting on the second day of the cycle for 21 days (now started on 1st day). A new course of tablets should be commenced 7 days after the cessation of the previous course. They should be taken at a fixed time of the day, preferably after a meal.

37. MECHANISM OF ACTION The combined oral pill suppresses pituitary hormones, FSH and LH peak and through their suppression prevents ovulation. At the same time, progestogen causes atrophic changes in the endometrium and prevents nidation. Progestogen also acts on the cervical mucus making it thick and tenacious and impenetrable by sperms. It also increases the tubal motility, so the fertilized egg reaches the uterine cavity before the endometrium is receptive for implantation

38. BENEFITS It effectively controls fertility. As it causes regular and scanty menstruation, it is useful in menorrhagia and polymenorrhoea . It prevents anaemia by reducing the menstrual loss. It has proved to lower the incidence of benign breast neoplasia such as fibrocystic disease. It reduces the incidence of functional ovarian cyst (50%) and ovarian and uterine malignancy The incidence of PID is reduced Reduced incidence of ectopic pregnancy is due to suppression of ovulation and reduction in PID. It protects against rheumatoid arthritis. Reduces the risk of anorectal cancer by 30–40%. It is useful in acne, PCOD and endometriosis.

39. SIDE EFFECTS Intermenstrual spotting Menstrual bleeding can become very scanty and occasionally a woman becomes amenorrhoeic causing undue fear of pregnancy. Oral pills are associated with monilial vaginitis. Carcinoma of the endocervix has been reported if used for more than 5 years but dysplasia is more frequent. OC is proved to increase the risk of breast cancer in a high-risk woman. The combined pills should not be offered to a woman suffering from cancer of the breast. Lactation is suppressed with combined pills. Carbohydrate tolerance may be reduced. Therefore, combined oral pills are contraindicated or cautiously given to a diabetic woman. Headache, migraine, depression, irritability, increased weight and lethargy can occur due to progestogen.

40. CONTRAINDICATIONS Cardiac disease, hypertension, smoker over 35 years. Diabetes. History of thrombosis, myocardial infarct, sickle cell anaemia, severe migraine. Chronic liver diseases such as cholestatic jaundice of pregnancy, cirrhosis of liver, adenoma, porphyrias . Breast cancer, gall bladder disease. Gross obesity. Patient on enzyme-inducing drugs like rifampicin, and antiepileptic except sodium valproate. 4–6 weeks prior to planned surgery. Lactating woman. Monilial vaginitis

41. TRIPHASIC COMBINED PILLS The triphasic preparations of EE2 and LNG contain during the first 6 days of the cycle 30 mcg EE2 plus 50 mcg LNG, for the next 5 days 40 mcg EE2 plus 75 mcg LNG, and during the last 10 days 30 mcg EE2 and 125 mcg LNG, followed by one medication-free week. These pills have no adverse effect on carbohydrate and lipid metabolism; therefore, they can be prescribed to diabetic women and without expecting any increased risk of myocardial infarct. They are as effective as the monophasic oral pills but not recommended in menorrhagia and for other indications.

42. MINI PILL/PROGESTOGEN ONLY PILL The lowdose POP (norethisterone 350 mcg, norgestrel 75 mcg or LNG 30 mcg) have been introduced to avoid the side effects of oestrogen in the combined pills. The tablet is taken daily without a break. The pill should be started within 5–7 days of the menstruation and taken at the same time with a leeway of 3 h on either side of the fixed time each day. Minipill does not have some of the major side effects of the combined pill and it is well suited for lactating women; some progestogens, in fact, increase milk secretion. Drawbacks are irregular bleeding (20%), amenorrhoea, depression, headache, migraine and weight gain, ectopic pregnancy, functional ovarian cysts besides a higher failure rate. Contraindications to POP are previous ectopic pregnancy, ovarian cyst, breast and genital cancers, abnormal vaginal bleeding, active liver and arterial disease, porphyria, liver tumour, valproate, spironolactone and meprobamate. B

43. ADVANTAGES Lactating women Women over 35 years Those with focal migraine Those intolerant to oestrogen or oestrogen contraindicated Diabetic, hypertensive woman, sickle cell anaemia SIDE EFFECTS weight gain irregular menstrual bleeding Depression breast cancer and thromboembolism

44. MECHANISM OF ACTION Cerazette ( 75 mcg desogestrel ) suppresses ovulation in 97–100%, whereas other progesterone only pills suppress ovulation in only 40%. It forms a thick plug of mucus in the cervical canal and acts as a barrier to sperms. It increases tubal peristalsis and fertilized egg reaches the uterine cavity too early for implantation.

45. DEPOT INJECTIONS Depot medroxyprogesterone acetate (DMPA) is given in microcrystalline aqueous suspension and norethisterone enanthate (NETO) in castor oil solution, both by deep intramuscular injection (not subcutaneous). A monthly injection of DMPA 25–50 mg, combined with 5 mg oestradiol is considered to be effective. Other preparations in use are the DMPA 150 mg 3-monthly, DMPA 300 mg 6-monthly and NETO 200 mg 2-monthly. ADVANTAGES DISADVANTAGES Injections are easy to administer, Long-acting, reversible. Menstrual irregularity and amenorrhoea The side effects of lipid and carbohydrate metabolism are avoided There is a delay in return of fertility. The incidence of PID, ectopic pregnancy and functional ovarian cysts is low, so also endometrial cancer. weight gain, depression, bloated feeling and mastalgia Avoids oestrogenic side effects. Contraindicated in breast cancer Can be given to a woman with sickle cell anaemia Decreases libido, causes dry vagina Coital independent. Prolonged use may reduce bone density mass and induce osteopenia.

46. SUBDERMAL IMPLANTS The subdermal implant has no ‘nuisance value’ of continuous compliance which often adversely affects motivation. Besides, nonoral system avoids ‘hepatic first pass effect and systemic side effects’. Norplant I (Figures 20.13–20.15) containing six silastic capsules has been withdrawn and replaced by a single rod implant. Norplant II ( Jadelle ) consists of two rods each containing 70 mg LNG. The daily release of hormone is 50 mcg and provides contraception for 3–5 years. ADVANTAGES DISADVANTAGES They are long-acting with sustained effect Breakthrough bleeding, irregular cycles, amenorrhoea Coital-independent Local infection may occur Systemic side effects are few and first pass effect on the liver avoided. Requires insertion and removal with nonbiodegradable capsules Can be used by lactating mothers and over the age 40. The implants are expensive

47. SILASTIC VAGINAL RINGS To reduce the side effects of systemic hormonal contraception and the surgical method of insertion of implants, silastic vaginal rings carrying different progestogens have now been introduced. contains LNG releasing 20 mcg of hormone daily and 15 mcg EE2. The contraceptive effect is mainly on the cervical mucus. Nuvaring contains 2.7 mg EE2 1 11.7 mg etonogestrel used continuously for 3 weeks and removed for 1 week. ADVANTAGES DISADVANTAGES Self-insertion and removal, good compliance Expensive Quick reversibility Local irritation Expulsion can occur.

48. SKIN PATCHES Hormonal patch (ortho-EVRA). Hormonal patch Elutes 150 mcg of norelgestromin and 20 mcg EE2 daily and the hormone lasts for 7 days. Three patches are required each cycle followed by 1 week patch-free interval. The patch should be applied within 5 days of menses over the buttocks, abdomen but not over the breasts The breakthrough bleeding (18%) and skin reaction (20%) breast discomfort are the side effects. GnRH, given continuously, suppresses FSH and LH and thereby ovulation. However, the drug is very expensive and long-term use causes osteoporosis.

49. CENTCHROMAN Centchroman is a synthetic nonsteroidal contraceptive taken as a 30 mg tablet, started on the first day of menses and taken twice weekly for 12 weeks and weekly thereafter (half-life is 170 h). It does not prevent ovulation. It prevents implantation through endometrial changes. Centchroman is not teratogenic or carcinogenic, exerts no pharmacological effect on other organs. The only side effect noted is prolonged cycles and oligomenorrhoea in 8% cases . It has been developed by Central Drug Research Institute, Lucknow, and has been released in India under the name of Saheli. Side effects :-Headache, nausea, vomiting,Gain in weight, Does not protect against HIV and STD, Some delay in return of fertility (up to 6 months). On Prolonged use—hyperplasia and atypical endometrium. Contraindications :- During 6 months of lactation, PCOD, hepatic dysfunction, cervical dysplasia, allergy to the drug.

50. 6.POSTCOITAL CONTRCEPTION Postcoital contraceptive agent interferes with postovulatory events leading to pregnancy and is therefore known as interceptive. It is also known as ‘emergency contraception’ method used to prevent pregnancy after an unprotected intercourse. Emergency contraception is used following rape, unprotected intercourse or accidental rupture of a condom during coitus taking place around ovulation. The preparations available include: Two tablets of relatively high doses of combined pill ( Ovran / Eugynon 50), containing 100 mcg EE2 and 1 mg norethisterone, or 500 mcg LNG, taken within 72 h of intercourse followed by two tablets taken 12 h later. MECHANISM OF ACTION:- The hormones may delay ovulation if taken soon after intercourse, cause corpus luteolysis , and bring about cervical mucus changes and endometrial atrophy.

51. LEVONORGESTRAL Prostinar tablet contains 0.75 mg LNG. One tablet should be taken within 72 h of unprotected intercourse and another 12 h later. Alternately, two tablets can be taken as a single dose. LNG prevents ovulation and causes desynchronization of endometrium through its receptors. Side effects are those of progestogens. The hormone is not teratogenic in case pregnancy does occur but risk of ectopic pregnancy remains. Contraindicated in liver disease, contains lactate, so allergy to galactose. The drug is also contraindicated in a woman with history of thrombophlebitis and migraine ADVANTAGES: It has no oestrogen and its associated side effects. It can be offered to hypertensive, cardiac and diabetic woman. It can be offered to a lactating woman. It can be given as late as 120 h after the unprotected intercourse. Single-dose therapy is an advantage

52. RU 486 (Mifepristone) RU 486 is a steroid with an affinity for progesterone receptors. It does not prevent fertilization but by blocking the action of progesterone on the endometrium, it causes sloughing and shedding of decidua and prevents implantation. It is not teratogenic. It causes delayed menstruation. Ectopic pregnancy is not avoided. The drug is expensive as compared to LNG. ULIPRISTAL Ulipristal is a synthetic progesterone hormone receptor modular, attaches to progesterone receptor and prevents/delays ovulation and suppresses endometrium, prevents implantation. A 30 mg tablet should be taken within 5 days. Side effects are headache and mood changes.

53. 7. IMMUNOLOGICAL METHODS Immunological approach to family planning is still in a developmental stage. The antigens which are being experimented upon are: b- hCG subunit (300 mcg) IM six-weekly 3 3 doses evokes specific antibodies and thereby produces temporary sterility for 1 year. Zona pellucida plays an important role in fertility. The zona pellucida antibodies can either prevent penetration of ovum by the sperm or prevent shedding of zona after fertilization so that implantation is impossible. Antibodies to sperm antigens. These trials have not yet proved successful in human beings. AntiFSH vaccine (inhibin) is also under trial.