For UG Class

1. Overview on Contraception
Dr. Sourav Chowdhury

2. Contraception
All measures temporary or
permanent, designed to prevent pregnancy
due to coital act.

3. Objectives
• Unwanted pregnancy
• Spacing between two child
• Prevention of sexually transmitted infection
• Avoid the risks of abortion
• In medical cases contraindicated to pregn.

4. ISSUES
• Decision made by individual or by couple
• Many factors influence decision:
– Advantages & disadvantages of various
methods
– Side effects & contraindications
– Effectiveness
• Perfect use vs. typical use
– Expense
– Spiritual/cultural beliefs
– Practicality of method

5. Basic Types
• Fertility awareness methods
• Barrier methods
• Situational methods
• Spermicides
• IUDs
• Hormonal contraception
• Operative sterilization

6. Natural Method
• Rhythm method
• Coitus interruptus (withdrawal)
• Lactational Amenorrhoea (LAM)

7. Rhythm Method
1. calendar rhythm
2. temperature rhythm
3. mucus rhythm

8. Calendar Method
• 1st unsafe period: deducting 20 days from
length of the shortest cycle
• Last unsafe period: deducting 10 days from
length of the longest cycle.
e.g. longest cycle 33 day & shortest cycle 28
day.
Unsafe period 8 to 23 day.

10. Temperature Rhythm
• Maintain Basal body temperature (Biphasic
pattern)-
• The BBT temp is maintained throughout 1st
half of cycle.
• First there will be a dip in temp by 0.5
degree-which coincides with ovulation.
• BBT will rise by 0.5 to 1 degree F, just 2
days after ovulation

11. Mucous rhythm
• Around ovulation there will be excessive
mucous secretion.
• Noting excessive mucus on vaginal mucosa

13. Success and Failure of use of
Contraceptives
• Typical Use: When contraception is not
used every time, or it’s not used according
to instructions every time.
• Perfect Use: When contraception is used
every time, and it is used according to
instructions every time.
• Efficacy: Unpredictable
• Perfect user failure rate 9%
• Typical user 12%.

14. Coitus Interupptus
• Requires control from male partner
• Ejaculating outside the female genital
tract
• But before ejaculation seminal secretions
occur, which contains sperm, so chance
of pregnancy is high

15. coitus interruptus (withdrawal)
• Very high failure rates
• Perfect use: 4%
• Typical Use: 15-28%
• Less sexual sensation
• More chance of ectopic pregnancy.

16. Ecotpic Pregnancy

17. Lactational Amenorrhea
• While baby is breast feeding, mothers
remain in amenorrhea.
• No ovulation & no pregnancy

18. Lam Criteria
1. Baby is being only breastfed
 The baby is not receiving any other solid food or liquids; only breast milk
Breastfeeding on demand
Breastfeeding at least every 4 hours
 No more than 4 hours between feeds during day
 No more than 6 hours between feeds at night
2. Amenorrhea – Menstruation has not returned since the birth of the child
 Bleeding during the first 2 months post-partum does not count as
menstruation
 Bleeding after 2 months post-partum can be an indication of the return
of ovulation and the return of fertility
3. The baby is less than 6 months old
 Biologically appropriate cut-off point.
 WHO recommends supplementing after 6 months.
 Supplemental food will decrease suckling.

19. MOA of LAM

20. BARRIER METHOD OF
CONTRACEPTION

21. DEFINITION
• The methods which prevent sperm
deposition in the vagina or prevent
sperm penetration through the cervical
canal- are called barrier methods of
contraception.
• The objective is achieved by mechanical
devises or by chemical means which
produce sperm immobilization, or by
combined means.

22. Barrier methods of
contraception
1. Male condom
2. Female condom
3. Diaphragm
4. Vaginal contraceptives (spermicides,
vaginal contraceptive sponge)
5. Cervical cap

23. Male Condom
• A male condom is one of the most
common types of barrier contraceptives.
• It is made out of either latex,
polyurethane, or lamb skin.

24. Non-contraceptive Benefits of Condom
1. Protect against STI (sexually transmitted
infections), gonorrhoea, chlamydia, HPV, HIV.
2. Protect against PID (Pelvic inflammatory disease).
3. Reduces incidence of tubal infertility & ectopic
pregnancy.
4. Protect against cervical cell abnormality.

25. Uses of Condom
1. As an elective contraceptive,
2. As an interim form of contraception,
3. During treatment of Pelvic infection
(Trichomonal vaginitis),
4. Immunological infertility.
5. During trans-vaginal ultrasound,
6. Semen collection for analysis,
7. As condom catheter.

26. Condom Catheter

27. Disadvantages
1. Accidental break or slip during coitus.
2. Inadequate sexual pleasure.
3. Allergic reaction (Latex).
4. Not reusable.
5. Failure rate are high 15/ HWY.

28. WHO MEC
1. A condition for which there is no restriction for
the use of the contraceptive method
2. A condition where the advantages of using the
method generally outweigh the theoretical or
proven risks
3. A condition where the theoretical or proven risks
usually outweigh the advantages of using the
method
4. A condition which represents an unacceptable
health risk if the contraceptive method is used

29. Failure Rate
• Used properly condom a success rate of
98%.
• Typical user failure rate is 15/ HWY.

30. Female Condom
• This type of contraceptive is put into the
vagina before having sex
• It has two ends with rings on them
• The end that goes into the vagina has a
closed rim
• The end that stays outside has an open rim
• 17 cm length

33. Cervical sponge
• This is an actual sea sponge
• It is inserted into the vagina before sex
• It has spermicide on it which is a
substance that kills sperm
• This substance kills the sperm before it
enters the uterus

34. Spermicides
• Available as vaginal foam, gel, cream,
tablet and suppository.
• Contain surfectants like nanoxynol-9,
octoxynol, banzalkonium bromide.

35. Classification
Hormonal Non-Hormonal
COC (Combined oral
contraceptives)
Centchroman (Saheli)
POP (Progesterone Only
Pills)

37. Mechanism of Action
• Inhibit ovulation: Both hormones acts
synergistically on the HPO axis.
• The release of GnRH from the
hypothalamus is prevented through a
negative feedback mechanism.
• So, no peak release of FSH & LH from the
anterior pituitary occurs.
• So, follicular growth is either not initiated or
if initiated –recruitment doesn’t occur.
• Resulting Anovulation.

38. Contraceptive action
• By Blocking Ovulation
• By altering cervical mucous
• By changing lining endometrium
• By altering fallopian tube motility

39. Generation
1st <1973 Norethistero
ne
2nd 1973-1989 LNG,
Norgestimate
3rd 1990-2000 Desogestrel,
Gestodene
4th > 2000 Drospirenon
e

40. DOSAGE

41. iNSTRUCTION
• New users should normally start their pill pack on
Day 1 of their menstrual cycle.
• 1 tab daily preferably at the same time (e.g. bed
time)
• Continue upto 21 days and then a 7 days gap.
• During this 7 days period there will be withdrawl
bleeding.
• Then start new pack on the 8th day (irrespective of
the withdrawl bleeding)
• 3 wks & 1 wk off
• Pill which contains 28 tabs have 7 placebo tablets,
so no need to give a gap.

42. IF SHE STARTS LATE
• She can start upto day 5.
• But has to take additional precaution
(condom) for next 7 days.

43. IDEAL CANDIDATES
• Age: menarche to 40 yr
• Newly married/ frequent sexual activity
• Non obese
• Normotensive
• Can take pills regularly without missing.
• No contraindications.

44. CONTRAINDICATION
WHO MEC cat-4
• Circulatory disease (present or Past)
• Liver disease
• Others

45. cIRCULATORY
• Arterial/venous thrombosis
• Severe Htn
• H/O stroke
• Heart disease (valvular, ischaemic)
• Diabetes with vascular involvement
• Migraine with aura

46. LIVER DISEASE
• Active liver disease
• Liver adenoma
• Liver carcinoma

47. OTHERS
• Pregnancy
• Breast feeding (post partum upto 6 wk)
• Major surgery or prolonged immobilization
• Estrogen dependent cancers (Breast
cancer)

48. WHO MEC cat-3
• Benign liver tumour
• Breast feeding (post partum from 6 wk to
6 month)
• Heavy smoker (>20 cig/day)
• Past H/O breast cancer
• Hyperlipidaemia
• Unexplained vaginal bleeding

49. WHO MEC cat-2
• Age ≥40 yr
• Smoker <35yr
• H/O jaundice
• Mild Htn
• Gallbladder disease
• Diabetes
• Sickle cell ds
• Headache
• Cancer cervix or CIN

50. INTERACTIONS
ADDITIONAL CONTRACEPTIVES
• Using broad spectrum antibiotics (ampicillin, tetracycline)
• Using enzyme inducing drugs (Burbiturates, Anti-epileptics,
Nevirapine).
REDUCES EFFICACY INCREASES EFFICACY
ASPIRIN BETA=BLOCKERS
ORAL ANTICOAGULANTS CORTICOSTERIODS
ORAL HYPOGLYCEMICS DIAZEPAM

51. MINOR AD
• Nausea, vomiting
• Mastalgia
• Weight gain
• Cholasma & acne
• Menstrual abnormalities (Break-through bleed,
Hypomenorrhoea, Menorrhagia, Post pill
amenorrhoea)
• Loss of libido
• White vaginal discharge (leukorrhoea)

52. MAJOR ADV
• Hypertension
• Depression
• Vascular complications (venous/ arterial
thrombo-embolism)
• Cholestatic jaundice

53. COC & NEOPLASIA
Protects against:
• Endometrial Ca
• Epithelial ovarian Ca
• Colorectal Ca
No direct relation with Breast cancer &
cervical cancer with low dose estrogen
COCs.

54. ADVANTAGES
• Highly effective
• Good cycle control
• Convenient to use
• Not intercourse related
• Reversible
• Additional non-contraceptive benefits.

55. NON-CONTRACEPTIVE
Improvement of menstrual abnormality:
• Cycle regulation
• ↓Dysmenorrhoea
• ↓Menorrhagia
• ↓ PMS
• ↓ Mittelsmerz’s syndrome
• Protect against anemia
• In patients with PCOS.

56. Non-contraceptive benefits
Protects against Cancers
• Endometrial Ca
• Epithelial ovarian Ca
• Colorectal Ca

57. Disadvantages
• Requires education & motivation
• Requires initial check-up & follow-up
• Risk of drug interaction & failure
• Side effects may develop
• Many contra-indications are there.
• Miss pill problems.

58. POP
• Pills that contain very low doses of a
progestin like the natural hormone
progesterone in a woman’s body.

59. MOA
• Work primarily by:
• – Thickening cervical mucus (this blocks
sperm from meeting an egg)
• – Disrupting the menstrual cycle,
including preventing the release of eggs
• from the ovaries (ovulation)

60. Effective
• Effectiveness depends on the user: For women who have
monthly bleeding, risk of pregnancy is greatest if pills are
taken late or missed completely.
• Breastfeeding women:
• As commonly used, about 1 pregnancy per 100 women
using POPs over the first year. This means that 99 of
every 100 women will not become pregnant.
• When pills are taken every day, less than 1 pregnancy
per 100 women using POPs over the first year(3 per 1,000
women).

61. Effective
• Less effective for women not breastfeeding:
• As commonly used, about 3 to 10 pregnancies per 100
women using POPs over the first year. This means that
90 to 97 of every 100 women will not become pregnant.
• When pills are taken every day at the same time, less
than 1 pregnancy per 100 women using POPs over the
first year (9 per 1,000 women).
• Return of fertility after POPs are stopped: No delay
• Protection against sexually transmitted infections (STIs):
None

62. Side-effects
• Changes in bleeding patterns including:
– For breastfeeding women, longer delay in return of monthly bleeding after
childbirth (lengthened postpartum amenorrhea)
– Frequent bleeding
– Irregular bleeding
– Infrequent bleeding
– Prolonged bleeding
– No monthly bleeding
• Breastfeeding also affects a woman’s bleeding patterns.
– Headaches
– Dizziness
– Mood changes
– Breast tenderness
– Abdominal pain
– Nausea
• Other possible physical changes:
– For women not breastfeeding, enlarged ovarian

63. Misunderstandings
Progestin-only pills:
• Do not cause a breastfeeding woman’s milk
to dry up.
• Must be taken every day, whether or not a
woman has sex that day.
• Do not make women infertile.
• Do not cause diarrhea in breastfeeding
babies.
• Reduce the risk of ectopic pregnancy.
Progestin-only pills:

64. IUCD
INTRAUTERINE
CONTRACEPTIVE DEVICE

67. TYPES
• Most common:
– T-shaped, copper bands on plastic
stem/arms
• Inserted in uterus through vagina and
cervical opening
• Strings:
– assure IUCD is in place; facilitate removal
• Most common copper IUCD: TCu-380A
• Less common: hormonal IUCDs

68. COPPER IUCD
Contents:
polyethylene, copper wire, &
barium sulfate for X-ray
visibility, threads

69. MECHANISM of ACTION
• Causes increase in uterine & tubal fluids
containing copper ions, enzymes,
prostaglandins, and macrophages that
impair sperm function and prevent
fertilization
• Prevent blatocyst implantation through
enzymatic inference

70. FAILURE RATE
1st Year Failure
per 100 women
Recommended
Lifespan
TCu 380A 0.3 10 years
Multiload Cu 250 1.2 3 years
Multiload Cu 375 1.4 5 years
TCu 200 2.3 3 years
Nova T 3.3 5 years

71. CHARACTERESTICS

72. WHO Eligibility Criteria for Contraceptive Use
Category Description
When clinical
judgment is
available
When clinical
judgment is
limited
1
No restriction for
use
Use the method
under any
circumstances Use the method
2
Benefits generally
outweigh risks
Generally use the
method
3
Risks generally
outweigh benefits
Use of method not
usually
recommended,
unless other
methods are not
available/acceptabl
e
Do not use the
method
4
Unacceptable
health risk
Method not to be
used

73. ELIGIBILTY:
Can be used safely by women who:
• Are of various age and parity
• Young and nulliparous women should be
– counseled on expulsion risk
• Are postpartum, post-abortion, or breastfeeding
• Have a chronic condition, including
• hypertension, cardiovascular disease, diabetes,
• liver or gall bladder disease

74. WHO SHOULD NOT INSERT IUD
• The copper IUD should not be inserted in women with
• Known or suspected pregnancy
• Cervical or endometrial cancer or unexplained vaginal
bleeding
• Malignant trophoblastic disease or known pelvic
tuberculosis
• Uterine distortion that impedes correct IUD placement
• Infection following childbirth or following
• Incomplete abortion

76. EXPULSION : CONTINUATION
• MULTIPARA,PNC INSERTION
• DURING M/C ,UT. CRAMPS
• DATA POPULATION COUNCIL & WHO
TRIALS
• PER 100 USERS PER YEAR
• EXPULSION 2-5
• MEDICAL REMOVAL 2-3
• PAIN, BLEEDING REMOVAL 8-10
• CONTINUATION 78-90 (ICMR TASK FORCE
1994)
• LEAVE DEVICE IN PROPER POSITION
• RETAIN MEMORY OF DEVICE

77. DISPLACED IUD
• 1-2 PER 1000 INSERTIONS CU T
• 0.5-1 PER 3000 INSERTIONS NEWER
DEVICES
• MISSING THREADS
• IN UTERO DISPLACEMENT
• PERFORATION –PERITONEAL CAVITY—
POD—BLADDER---RECTUM
• SOUNDING,X RAY, USG

79. IMMEDIATE COMPLICATIONS
SYNCOPAL ATTACK
PAIN
PERFORATION
FAILED INSERTION

81. PAIN
DYSMENORRHOEA
DISPARITY BET. IUD SIZE & UT. CAVITY
SIZE
PRE EXISTING INFECTION
PID
PERFORATION

82. MENSTRUAL PROBLEMS
IUCD MENORRHAGIA
INCR. PLASMINOGEN ACTIVITY ENZYME
LYSIS OF FIBRIN
INCR. VASCULARITY
SURFACE CONTACT
INTER M/C SPOTTING

83. RISK ECTOPIC PREGNANCY
• INCR. RISK OF ECTOPIC
• TUBAL INFECTION, BLOCKS
• TUBAL MOTILITY
• PROGESTERONE IUCD-MORE

85. EMERGENCY CONTRACEPTIVES

86. Indications of EC
1. UPSI
2. Condom rupture
3. Missed pill
4. Delay in taking POP
5. Sexual assault or Rape

87. OPTIONS
1. Levonorgestrel (LNG)
2. Cu-IUD
3. Ulipristal acetate (UPA)
Others:
4. Ethinyl Estradiol
5. Yuzpe method
6. Mifepristone

88. LEVONORGESTREL
• Progestogen hormone.
• 2 tablets 0.75 mg or 1.5 mg single oral
dose.
• Licensed for use within 72 hours of
UPSI or contraceptive failure.

89. LEVONORGESTREL
Dose 1.5mg Single oral dose
MOA-
• Work primarily by inhibition of ovulation.
• Administration of LNG appears to prevent
follicular rupture or cause luteal
dysfunction.
• Not effective once the process of
fertilisation has occurred.
• LNG does not affect embryo-endometrial
attachment.
• Action on cervical mucus also helps.

90. EFFECTIVENESS
• How Effective- The efficacy of LNG has
been demonstrated up to 72 hours after
UPSI.
• But it can be also be used upto 120 hr.

91. COPPER-IUCD
MOA-
• Copper is toxic to the ovum and sperm and
thus the copper-bearing intrauterine device
(Cu- IUD) is effective immediately after
insertion and
• works primarily by inhibiting fertilisation.

92. CU-IUCD
TIMING
Timing- Within the first 5 days (120 hours)
following first UPSI in a cycle
or
within 5 days from the earliest estimated
date of ovulation.

93. HOW EFFECTIVE
• the failure rate for use of the Cu-IUD as EC
is 0.1%. So, it’s the GOLD Std.
• Contraindications- Use of an Cu-IUD for
EC carries the same contraindications as
routine Cu-IUD insertion.
• Side-efffects- Pain is a common side effect
associated with insertion.

94. Ulipristal Acetate (UPA)
• Progesterone receptor modulator
• Dose- 30 mg single oral dose
• Timing- within 120 hours of UPSI

95. Ulipristal Acetate (UPA)
MOA-
• Inhibition or delay of ovulation.
• Can prevent ovulation after the LH surge
has started, delaying follicular rupture until
up to 5 days later.

96. Ulipristal Acetate (UPA)
• UPA is the only oral method licensed
for use between 72 and 120 hours.

97. Side-effects
• Headache,
• nausea and
• altered bleeding patterns are common.

98. Contraindications
• Where multiple episodes of UPSI have
occurred and there is a risk pregnancy, UPA
should not be used.
• Breastfeeding is not recommended for up to
36 hours after ingestion of UPA
• Hepatic dysfunction
• Severe asthma

99. Can UPA be used more than once
• UPA should not be used more than once
in a cycle or concomitantly with LNG
• If there has been an earlier episode of UPSI
outside the treatment window (>120 hours)
LNG can be repeated but not UPA.

100. Morning After Pill
• Ethinyl Estradiol 2.5 mg twice daily for 5
days.
• Starting within 72 hr of UPSI.
• Not preferred now a days.
• Nausea/ vomiting.

101. YUZPE method
Combined hormonal regimen
• High dose COC (EE 50 mcg + LNG 250
mcg) e.g.Ovral.
• Should be started within 72 hr of UPSI.
• 2 tabs stat and 2 after 12 hr
• Nausea/ vomiting can be very severe, use
of anti emetics recommended.
• Not preferred now a days.

102. Mifepristone
• Also called RU 486.
• Anti progesterone
• Binds with progesterone receptor but
causes no action.
• Due to lack of progesterone, implantation
is hampered.
• Basically its not contraception but
interception.

103. Mifepristone
• Can be used upto 17 days after UPSI.
• Single dose of 100 mg tab to be taken.
• Pregnancy rate is 0.6%.
• If pregnancy occurs, it is to be terminated.
• Mifepristone is rarely used as EC.

104. Drugs Dose Pregnancy rates
LNG 1.5 mg single dose within
72 hr
0-1%
Cu IUD (Gold Std) Within 5 days of UPSI 0- 0.1%
(BEST)
UPA 30 mg single dose within
120 hr
0-1 %
Yuzpe (EE 50 mcg + LNG
250 mcg)
2 tab within 72 hr and
repeat 2 tab after 12 hr
0-2 %
EE 2.5 mg 2.5 mg twice daily x 5days
(starting within 72 hr of
UPSI)
0-0.6 %

105. Thank you for not yawning….!