Transcript 21. fp+contr - UMF IASI 2015

FAMILY PLANNING &
CONTRACEPTION
ASSOCIATE PROFESSOR
IOLANDA ELENA BLIDARU
MD, PhD
FAMILY PLANNING
Aspects of the problem
 national
 social
 personal
 ethnic
In no other branch of medicine are
social, religious, and political forces
more obvious than in family planning.
CONTRACEPTION

Definition – avoiding an unwanted
pregnancy
Elective abortion is not a contraceptive
technique.


no contraception + presumably fertile sex partners
= about 90 % of women will conceive within 1 year.
While there is no totally safe contraceptive method,
and the lack of contraception is even more
dangerous, both are less dangerous than driving an
automobile for 1 year.
CONTRACEPTION

Classification of the methods
1. the
user – male / female
2. the duration – temporary (reversible) /
permanent (irreversible)
3. the type: hormonal, mechanical, chemical,
natural, surgical, mixed
4. emergency or routine contraception
CONTRACEPTION

Effectiveness – Pearl Index
Total no. of accidental pregnancies x 1200 / total months of use =
% per 100 women-years of exposure

Failure rates for some methods vary
considerably, largely because of the potential
for failure caused by imperfect use (user
failure) rather than an intrinsic failure of the
method itself.
CONTRACEPTION
The characteristics of the ideal
contraceptive method
•
•
•
•
•
•
•
•
•
highly effective
no side effects
cheap / gratis
independent of intercourse
rapidly reversible
widespread availability
acceptable to all cultures and religions
easily distributed
easily administrated (by non - healthcare personnel).
CONTRACEPTION
Contraceptive



counselling
the contraceptive choice
the provision of method
the advice on using the method
CONTRACEPTION
Classification






Hormonal contraception
Intrauterine contraception
Copper intrauterine device (IUD)
Hormone-releasing intrauterine system (IUS)
Barrier methods Condoms (male, female)
Female barriers
Natural family planning methods: Periodic
abstinence, Coitus interruptus, Lactation
Emergency contraception
Sterilization Female sterilization
Vasectomy
CONTRACEPTION
 Hormonal contraception
1) Combined oral contraceptive pills (COC)
2) Combined hormonal patches
3) Vaginal ring
4) Progestogen-only preparations
- Progestogen-only pills (POP)
- Injectables
- Subdermal implants
Hormonal contraception
•
Combined hormonal
patches – Ortho Evra
•
Vaginal ring NuvaRing
etonogestrel + EE
Hormonal contraception
Progestogen-only
preparations
Progestogen-only pills (POP) – Cerazette
contains desogestrel.


Injectables
- norethindrone enanthate (NET – EN)
– 8 weeks
- medroxiprogesteron acetate depot
(DMPA) – 12 weeks
Hormonal contraception
Subdermal implants
 delivery of a steroid
progestin from polymer
capsules or rods placed
under the skin.
 Implanon - 4 cm/ 2 mm
Implanon rod contains 68
milligrams of etonogestrel
which is released over a 3
year period.
COMBINED ORAL
CONTRACEPTIVE PILL
Formulations
1.
2.
3.
Monophasic (each tablet contains a fixed
amount of estrogen and progestin);
Biphasic (each tablet contains a fixed amount
of estrogen, while the amount of progestin
increases in the second half of the cycle);
Triphasic (the amount of estrogen may be
fixed or variable, while the amount of
progestin increases in 3 equal phases).
Estrogens
 Types
of estrogen
ethinyl estradiol,
mestranol, a “prodrug” that is converted in
vivo to ethinyl estradiol.
estradiol, ex: Zoely - acetat de
nomegestrol + estradiol
estetrol
Progestins
Progestins can be classified according to their
chemical structure as
19-nortestosteron derivatives: norethisteron,
linestrenol, etinodiol diacetat şi levonorgestrel;
17 alfa-hidroxiprogesteron derivatives:
medroxiprogesteron acetat, clormadinon acetat,
cyproteron acetate;
progestines of the new generation:
desogestrel, gestodene, dienogest, norgestimate
spironoloctone derivatives - drospirenone

EFFICACY
 The
combined OC = a highly effective
method of reversible contraception.
 With perfect use, the combined OC is
99.9% effective in preventing pregnancy.
 However, typical use = failure rates
range from 3 - 8%.
MECHANISM OF ACTION
Main
mechanism of action
is to
suppress gonadotropin
secretion,
thereby
inhibiting ovulation.
MECHANISM OF ACTION
 Additional
1. endometrial
mechanisms of action
atrophy, making the endometrium
unreceptive to implantation;
2. Increased viscousity of the cervical mucus impedes sperm transport;
3. effect on fluid secretion and peristalsis within
the fallopian tube, which interferes with ovum
and sperm transport.
INDICATIONS
 In
the absence
of contraindications,
use of the combined OC
may be considered for
any woman seeking
a reliable, reversible,
coitally-independent
method of contraception.
CONTRAINDICATIONS
 The
World Health Organization
(WHO)
has developed a list of
absolute and relative
contraindications
to the use of combined OCs,
based on the available
evidence of risks
ABSOLUTE CONTRAINDICATIONS
< 6 weeks postpartum if breastfeeding
2. Smoker over the age of 35 (≥ 15 cigarettes per day)
3. Hypertension (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg)
4. Current or past history of venous thromboembolism (VTE)
5. Ischemic heart disease
6. History of cerebrovascular accident
7. Complicated valvular heart disease
8. Migraine headache with focal neurological symptoms
9. Breast cancer (current)
10. Diabetes with retinopathy / nephropathy / neuropathy
11. Severe cirrhosis
12. Liver tumour (adenoma or hepatoma)
1.
RELATIVE CONTRAINDICATIONS
1.
2.
3.
4.
5.
6.
7.
8.
Smoker over the age of 35 (< 15 cigarettes per day)
Adequately controlled hypertension
Hypertension (systolic 140–159mm Hg,
diastolic 90–99mm Hg)
Migraine headache over the age of 35
Currently symptomatic gallbladder disease
Mild cirrhosis
History of combined OC-related cholestasis
Users of medications that may interfere with
combined OC metabolism
SIDE-EFFECTS
Some
combined OC users will
experience minor side-effects,
most commonly during the
first 3 cycles.
These side-effects may lead to
discontinuation
of the combined OC.
SIDE-EFFECTS
The most common reason patients
discontinue combined OC use
1. Abnormal menstrual bleeding,
2. Nausea,
3. Weight gain,
4. Mood changes,
5. Breast tenderness,
6. Headache.

WEIGHT GAIN
 Placebo-controlled
trials have failed
to show any association between
low-dose combined COC and weight gain.
 Studies
comparing the COC to other
contraceptive methods have failed to
show a significant associated weight gain.
BREAST CANCER
 The
risk of breast cancer in combined OC
users is still controversial.
 The
research suggested that there was a
small but significant increase in risk of
breast cancer in women who are smokers
and currently taking the combined OC
and in the first 10 years after
discontinuing it.
CERVICAL CANCER
 Long-term
COC use may increase
the risk of cervical cancer in
women who are HPV positive but
not in women who are HPV
negative.
 Infection with HPV,as the major
risk factor for cervical cancer, is
related to sexual behaviour.
NON-CONTRACEPTIVE BENEFITS
Decreased
endometrial
cancer
2. Decreased
ovarian
cancer
3. Decreased
risk of
fibroids,
endometriosis
1.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Cycle regulation
Decreased menstrual flow
Increased bone mineral density
Decreased dysmenorrhea
Decreased peri-menopausal
symptoms
Decreased acne
Decreased hirsutism
Decreased incidence of
salpingitis and PID
Possibly fewer ovarian cysts
Possibly fewer cases of benign
breast disease
Possibly less colorectal
carcinoma
1. PATIENT ASSESSMENT
Before prescribing a COC, a thorough
history should be taken, including
potential contraindications,
smoking history, and medications.
 The physical examination should
include a blood pressure
measurement.

1. PATIENT ASSESSMENT
No
routine laboratory
screening is required.
2. Counselling
I.U.D.
(Intra Uterine Device for
contraception)
First generation
I.U.D.is
Lipes loop
Second generation
I.U.D. is
Copper T-200
Third generation
I.U.D. is
Gyne-T 380
With 8 years
Intra uterine life
MIRENA
Jaydess
A capsule on the
Stem contain mixture
Of silicon rubber &
60mg of progestin
60mg
Levonorgestrel
Developed by steroid
research Laboratory-Finland
Forth generation
I.U.D.
releasing 20mcg per day
estimated to last 5 years.