CONTRACEPTION

Definition: It is prevention of pregnancy without prevention of coitus.

I.NATURAL FAMILY PLANNING

SAFE PERIOD / ADAPTATION OF COITUS / PROLONGATION OF LACTATION

Advantages: No physical side effects,no medical contraindications.

Requires: Educated motivated couples +..........

Disadvantages: High failure rate[20/HWY] + Limitation of intercourse.

A-SAFE PERIOD:

Idea: Avoid coitus during the fertile days in the menstrual cycle

Methods of identification of fertile days:

1- Calendar method:

-If regular cycles then to calculate the 1st day of the unsafe period subtract 18 from the cycle duration and to calculate the last day subtract 11.

-If irregular cycles: [better to use another method for contraceptions]

1. Record the length of each cycle for 8 months.

2.Subtract 18 from the shortest cycle & by subtract 11 from the longest cycle. The calculated period between the above 2 days represents the unsafe period.

2- Basal body temperature chart:

Coitus is allowed 3 days after occurence of the thermogenic shift.

3- Cervical mucous method-

Coitus is allowed in 3 days after the last day of abundant ,slippery discharge.

4- Symptothermal method:

Combination of B.B.T method, cx mucous method.

B-ADAPTATION OF COlTUS TECHNIQUES:

Disadvantages: high failure rate, decrease pleasure, and first part of secretion contains sperm.

1-Coitus interruptus: withdrawal of erect penis from vagina before ejaculation,

2-Coitus interfemoris: ejaculation in between the thighs

3-Coitus reservatus: Vaginal penetration but restriction of movement so no ejaculation occurs inside the vagina.

C- PROLONGED LACTATION [PRL inhibits ovulation]

II-MECHANICAL BARRIER METHODS

Prevent sperm from reaching upper female genital tract

Male:Condom.

Female: Occlusive pessaries as, diaphragm, cervical cap, vault cap, venule. Spermicide. Vaginal sponge.

Adv.:No systernic side effects., reversible, protect against STD.

Disadv.: Coitus related, decreased pleasure..

1-The male condom:

-It is a thin,lubricated latex sheath worn over the erect penis[addition of spermicide guards against its tearing].Penile withdrawal should be done while the penis is still erected to avoid spilling semen into the vagina.

-Advantages:

1-Protects against STD.[No complete protection against HPV?]

2-Used in immunological infertility.

3-TTT of premature ejaculation.

4-Maintenance of erection.

-Disadv.:

1.High failure rate

2.Not accepted by some [believe it decreases penile sensation.]

2-Femisheath [The female condom]:

A female condom was designed formed of 2 rings, inner one to fit onto the cx. and an outer one to fit onto the external female genitalia & base of the penis.The body of the sheath is 15cm long.

Adv.:Better protection against HPV&HIV viruses+not related to penile erection.

3-Vaginal Diaphragm:

-Made of a dome-shaped rubber cup with a thick metallic flexible rim.

-Available in different sizes and shapes.[e.g Coil spring,flat spring]

-Inserted so that the posterior rim is in the posterior fornix while the anterior rim is bridging above the S.Pubis.The largest fitting size should be selected., and should be left in place for 8 hrs after coitus but not more than 24 hrs.

Size is the distance between the posterior fornix and back of symphisis pubis.

-Disadv.:Not used in cases of prolapse,weak P.F+may cause bladder irritation.

4-Cervical cap :

-It is a miniature diaphragm applied directly to the cx. [with a spermicide]

-Available in different sizes&shapes as Prentif,Vimule & Dumas[Vault cap]

5-Vaginal sponge :

-A mushroom-shaped sponge with a dimple in the upper surface for fitting against the cx.It contains 1gm Nonoxynol 9.Can be used for 24hrs even with multiple intercourses to be removed 6 hrs after the last coitus.

[[All barriers are better used with spermicides]]

III.SPERMICIDES

-These are chemical compounds lethal to sperms.

Adv:Protection against STD[especially surface active agents].

Disadv.:Applied before every intercourse,Inconvience of use, high Failure rate.

There are 5 main groups of Spermicides:

1.Acids : Known since ancient years.

2.Bactericides [Quinine Sulphate]not used anymore due to toxicity.

3.Surface active agents: Most important gp. they act by disruption of the sperm membrane and interfere with O2 uptake&fructolysis.

Include: Nonoxynol 9,10,11.,Octoxynol,Menfegol,BenzalKonium[Most potent]

4.Enzyme inhibitors: Gossypol that inhibits hyaluronidase and proacrosin. Active locally ,and orally as male contraception.

5.Local anesthetics: Used to inhibit sperm motility.

*Forms: Supplied as: Vaginal tablets&Suppositories[Most popular]

Foam ,cream,&gel.

*Not used in cases of allergy to active ingredient or the carrier base.

*Used 5-30 min before coitus that must occur in <2hrs.No douching for 6hrs

IV.HORMONAL CONTRACEPTION

TYPES:

-Combined pills

-Progesterone only contraception [Pills, Injectables ,Implants ,Vaginal rings , Biodegradable systems , Progesterone medicated IUD].

-GnRH agonist

COMBINED ORAL CONTRACEPTIVE PILLS

Estrogen's used e.g.: Ethinyl estradiol, Mestranol [30 - 50 Ugm / pill]

Progestogen used e.g.: Norethisterone, levonorgestel [1 - 0.5 mg / pill]

Types according to E/P content:

i. Monophasic pills: pills with same dose all through the course..

ii. Biphasic pills: fixed dose of estrogen + more prog. in the last 14 days.

iii. Triphasic pills: variable dose of estrogen + variable dose of prog.

iv. Sequential pills: fixed dose of estrogen. No progesterone for 1st, 7days, then progesterone for 14 days (not used now ..why ?).

Triphasic pills contain the least amount of progestogens.

Types according to E content:

-High dose: E content 80-100 mcg.

-Low dose: E content 30-50 mcg.[Norminest - Ovral]

-Lowest dose: E content < 30 mcg.

Mode of action:

1. Inhibition of ovulation as it inhibit pulsatile release of Gn H.

2. Alteration of endometrium: inadequate secretory, edematous.

3. Altered Cx mucous: hostile to sperm penetration (progestogen effect)

4. On fallopian tube: alter motility and reduce secretions.

5. On ovary: Suppression of corpus luteum function.[Luteolysis]

Indications of OCP:

1. Contraception.

2. Non contraceptive uses:

-Dysmenorrhea, PMT, Menorrhagia.

-Control of DUB

-Endometriosis

-Regression of functional Ov. cysts.

-Supression of lactation.

-E+P challenge test in amenorrhea.

Administration: On 1st [Previously from 5th day of the cycle] day of the cycle for 21 days then for one week rest, then administration for a next course.

Failure rate : 0.1-1/HWY.

Management of missed pills:

I. If one pill or 2 pills missed, they are taken when remembered.

II. It 3 pills are missed: wait till withdrawal bleeding ,then start another cycle, the patient must use extra-precautions for next 2 weeks.

COMPLICATIONS AND ADVERSE REACTIONS OF PILLS:

I-MENSTRUAL EFFECTS:

1.Break through bleeding: Related to E/P balance if occurs early in the cycle =>change to tab. with more E .If occurs late=> change to tab. with more P.

2.Failure to have withdrawal bleeding [with low dose&lowest dose pills] exclude preg., restart pills [may E content] after 7 days.

3-Postpill amenorrhea: it is due to persistent supression of Hypoth.-pit-Ov. axis & responds well to ovulation induction.

4-Hypomenorrhea : usually beneficial.

Other Menstrual disturbances may also result from:

-Forgetting of pills.

-Drugs interfering with action of pills[as Antibiotics,Barbiturates].

II.MINOR & MORPHOLOGICAL DISTURBANCES:

1. Nausea +Vomiting [related to E content]

2. Headache and migraine, depression, mood&Lipido changes[P].

3. Chloasma, acne,oily skin, hirsutism[P]

4. Breast fullness&mastalgia[E content].

5. Weight gain[anabolic effect of P or cyclical wt. gain due to E]

III.SYSTEMIC&METABOLIC EFFECTS:

1-C.V.S:

a)Venous thromboembolic manifestations[related to E content]

b)Arterial Ischemic complications[related to P content]

c)Systemic hypertension[related to P,&normalizes after stopping pills]

2-Liver&gall bladder:

a)Cholestasis with increase in liver enzymes.

b)May accelerate GB dz in susceptible patients.

3-Altered CHO metabolism:

Dose related antiinsulin effect of E&P affecting glucose tolerance.

IV.RELATION TO BENIGN&MALIGNANT TUMOURS:

1-Breast Carcinoma: Only in cases of sequential pills.

2-Hepatic adenoma: Very rarely OCP may lead to its occurrence.

3-Ovarian&Endometrial carc.: Protective effect up to 10yrs after stoppage

4-Benign Breast dzes& uterine Fibroids: OCP seem to be protective.

5-May increase the incidence of CIN .

CONTRAINDICATIONS OF COC:

ABSOLUTE CONTRAINDICATIONS:

1-Cerebrovascular accidents, thromboembolic disease or Tendency to thromboembolism e.g Before &after surgery.

2-Cardiovascular disaease

3-Coronary heart disease

4-Pregnancy or lactation.

5-Hepatic adenoma

6-Impaired liver functions

7-Malignancy of the genital tract or breast.

RELATIVE CONTRAINDICATIONS:

1-Severe vascular or migraine headache.

2-Hypertension

3-Diabetic , or potentially diabetic

4-Gall bladder disease

5-History of cholestasis with pregnancy

6--Age limitations:

-Age of 40or older.

-Age of 35 with risk factor for vascular Dz[Obese,Smoker...]

-Age of 30 if heavy smoker.

7-Fibroadenosis of the breast

8-Fibromyoma of the uterus.

9-V.M till -ve B-HCG

10-Varicose viens

PROGESTERONE ONLY CONTRACEPTION

COMMON ADVANTAGES:

1-No E content=>No E side effects

2-Minimal progstagen side effects: Can be used during lactation (enhance milk production) ,in obese pts,CVS dz,smokers,old,liver dz

3-Protect against STD

1-Progestin only oral pills

Mode of action:

1-Thick impermeable cervical secretions.

2-Edometrium=>Atrophic changes not suitable for implantation

3-Since P content is minimal so inhibition of ovulation occurs in small No of patients.

4-Alteration of tubal motility.

Administration:

One tablet taken daily at a fixed time continuously without rest periods.

Disadvantages:

1-Higher failure rate than COCP.3/HWY

2-Irregular menstrual pattern with break through bleeding[never ttt with E ] ,oligomenorrhea and variable periods of amenorrhea.

3. Increased incidence of ectopic gestation.

Contraindication:

- Suspected pregnancy . - Previous ectopic pregnancy.

-Undiagnosed GT bleeding -Malignant breast condition

2-Injectable Progestin contraception

A-Intramuscular : *DMPA *Net-OEN

-Depot Medroxy Progesterone Acetate 150mg deep IM inj./3months

-Norethinodrone Oenanthate 200mg deep IM inj/2months.

Mode of action:

As POP but since Prog. in injectables is potent it inhibits Ovulation.

Advantages [over POP]:

1-Higly reliable with failure rate < 1/HWY

2-Readily acceptable .

3-Long acting,can be used in forgetful patients.

+ other common advantages

Disadvantages:

1-High incidence of menstrual disturbances,[may be ttt with E].

2-Delayed return of fertility[till hormone is metabolized]

3-Some P side effects: Wt gain,headache,decreased lipido,mild antiinsulin effect.

Contraindications:

As POP + Young couples where preg. is requested as soon as drug is omitted.

3-Subcutaneous implants[NROPLANT]

-Norplant system consists of 6 silastic capsules,each 34mm long&2.4mm in dtr

-Each capsule has 36mg levonorgestrel,they are implanted in a fan shaped manner into the SC fat of the medial side of the upper arm via a 2mm incision.

-Can be used for up to 5yrs, can be removed when preg. is requested.

-Levonorg. is released in a rate of about 35 mcg/d after 6months of use.

Adv.:-Highly effective [0.2/HWY for 2yrs,then 1/HWY for 3yrs]

-Readily reversible.

4-Biodegredable levonorgestrel capsules[Capronor]

Levonrg. in oily solution lasts 18 months .

5-Biodegredable norethinodrone pellets.

4 pellets for 12 months.

6-Norethinodrone injectable microsheres.

Injection/3months

7-Steroid vaginal Silastic rings

[P only/1-6m or P+E/3wks+1wk rest]

8-Monthly injectables

[E+P e.g Cycloprovera]

V.INTRAUTERINE CONTRACEPTIVE DEVICE

I. U. D

Types: [see diagram]

I. Inert or non medicated Devices [Polythene impregnated with barium]

e.g: Lippes loop, Safe T coil.

II. The medicated or Bioactive Device:

a)Copper-medicated Device e.g Cu T, Cu 7 , Nova T, Multiload.

b)The progesterone-Medicated Device: (Progestasert).

c)The antibleeding medicated device with antipg or antifibrinolytics

MECHANISM OF ACTION OF I.U.D

Main Mechanism of action:

1.Aseptic endometritis: Inflammation==>Phagocytosis of sperms + aggregation of PNL & production of several lymphokines..

2.Acceleration of tubal and uterine motility

3.Increase local production of PG=> inhibits implantation of fertilized ovum.

4.May interfere with sperm transport.

Effects of copper : [In IUD medicated with Cu]

1.Copper increases the inflammatory reaction.

2.Copper inhibits carbonic anhydrase[due to competition with Zn],so it may be toxic to the blastocyst & the sperms and inhibits implantation.

3.Cu may render cx. mucous hostile to the sperms

4.Cu may decrease steroid receptors in the endometrium[esp. P]

Effects of Progesterone : [In IUD medicated with prog.]

- Progesterone act locally=>Atrophic endometrium+Impermeable cx.mucous.

Advantages:

Reliable, Reversible.One decision method for long periods. How Long?

INSERTION

Time of insertion:

-Postmenstrual, immediately after 1st trimester abortion, 1 wk after 2nd trimester abortion, 6 weeks after labour, postcoital.

-Insertion may be by pushing or withdrawal method.
Instructions to the patient.

- Spotting, cramp and abdominal pain after insertion.

- Felling threads after each cycle.

- Warning symptoms: pyrexia, pain, purulent discharge.

CONTRAINDICATIONS

Absolute:

1- PID :Active, recent or recurrent.

2-Pregnancy: Known or suspected.

3-Amenorrhea of undiagnosed cause

4-Bleeding of undiagnosed cause.

5-History of Ectopic pregnancy

6-Suspected or confirmed Genital malignancy.

Relative:

1-Congenital uterine or cervical malformations.

2-Dysmenorrhea.

3-Fibroids of uterine body or cervix

4.High risk patients for PID

5.Impaired coagulation.

6-Others: Allergy to Cu, Severe Anemia,Wilson's disease...

COMPLICATIONS

1-Genital bleeding:

In the form of postinsertion spotting, menorrhagia,[reassurance] or metrorrhagia[in this case exclude pathology].

-Bleeding is related to the endometrial trauma (hence to the size of the IUD) and to Pg production. ==>anti PG, antifibrinolytics and tonics are usually effective.If severe remove I.U.D + D&C.

2-Pelvic infection: P.I.D = = = > Remove IUD + Proper ttt.

Actinomyces Israelii a gram +ve filamentous anaerobe that colonizes in the cx. of IUD users may cause PID with more risk of peritonitis and ov. abscess.

IUD with lower incidence of PID=>Medicated, Monofilamentous threads or no threads.[Multifelamentous Dalcon shield had high incidence of PID]

Managment:

Remove the IUD + Proper treatment.

3-Vaginal discharge: Watery,Mucoid --> no treatment if not infected

4-Ectopic pregnancy: Progestasert increases incidence of ectopic preg.5% of preg. on IUD are ectopic as IUD protects against IU preg. but not extraut.

5-Pain with IUD may be due to:

*During and immediately postinsertion pain+syncope may be due to passage of IUD through the int. cx os or due to perforation.

ttt=>Exclude perforation + reassurance.

*IUD larger than uterine cavity=>Spasmodic dysm. or abd. cramps (analgesic+ change to smaller size)However if congestive dysm.= exclude infection.

*Partial expulsion with the IUD in the cx.canal =>Penile pain [remove IUD]

Serious causes of pain to be excluded: Sp. Abortion, Ectopic, PID

6-Expulsion: 5% of IUD undergo sp.expulsion which is accompanied with pain, spotting, discharge or may pass unnoticed.Partial expulsion leads to penile pain during intercourse.

Expulsion is due to: inapropriate size of IUD, Uterine or cervical anomaly, improper insertion, Pregnancy [cause or result].

7-Perforation: Perforation may be partial [IUD embedded in uterine wall] or complete[IUD passes out of the uterus].Occurs due to.......

8-IU Pregnancy: IUD have typical failure rate of 2-6/HWY. If pregnancy occurs while IUD is in place there is 50% chance of Sp.abortion compared to 25% chance if it is removed.

Thus if the threads are present if is better removed but if they are missed, IUD is left, to be looked for after delivery in the maternal surface of the placenta or embedded in the uterine wall.

In any case pregnancy is viewed as high risk.Why?

9.Missed threads: Causes :

*Short,Cut,or retracted threads or short fingers

*Long vagina or threads adherent to vaginal vault

*Expulsion of I.U.D. after insertion

*Pregnancy: retraction of threads by pregnant uterus.

*Perforation: partial or complete usually during insertion

Management of missed threads:

				History / Examination + Speculum
Threads found					Threads absent
Pt education					Pregnancy test
		Positive pregnancy test			Negative pregnancy test
	Exclude Ectopic =>managment + no IUD again				Pelviabd X ray
				IUD absent		IUD present
			= Expulsion =>Management ?
						-Hysteroscopy or -U/S or -Another X-ray with: HSG, IU dilator or sound
				IUD intra- uterine		IUD extra-uterine
		Removed by: Hysteroscope, Bozeman or crockodile forceps, + D&C			Removed by: Minilaparotomy, Laparoscopic retreival, posterior culdotomy.
		Only inert open IUD may be left in the peritoneal cavity.

After any result be sure to provide the patient with a suitable method of contraception.
VI. FEMALE STERILIATION:

Indications

1. Complete famliy slze

2. Medical disease contraindicating pregnancy

3. Inherited disorders.

Contraindications:

1. Marital problem and young females with psychosis.

Methods:

A-Hysterectomy if associated indication

B-Tubal sterilization:

I.During C.S, postpartum, post-abortive.

II.Interval strilization:

Transabdominal

a) Laparotomy b) Minilaparotomy c) Laparoscopy.

Transvaginal

a) Culdoscopy b) posterior colpotomy.

Transcervical

Hysteroscopy & Injection of sclerosing material through the tube.

Methods of tubal ligation at laparotomy:

Pomeroy: double ligation + excision of a loop of the tube.

Irving: Proximal part embedded in the myometrium.

Madlner: Crushing and ligation of a loop of the tube.

Methods of laparoscopic sterilization

- Diathermy - Rings - Clips.

Causes of failures:

1. Serilization at mid cycle

2. Recanalization.

3. Ligation of round lig.

Complications:

Early: Complications of surgery (Laparotomy or laparoscopy), anesthesia,

, pain due to tubal ischemia.

Late:

1-Post tubal ligation syndrome: Anxiety, bleeding (menorrhagia), pain (Congestive dysmenorrhea)

2-Ectopic pregnancy.