3.3 Family Planning
3.3 Family Planning
3.3 Family Planning
According to FHS published in 2011, maternal mortality rates… TUE – overall rate of effectiveness in actual use of a particular
contraceptive method taking into consideration human errors
FAMILY PLANNING PUE – the rate of effectiveness of a contraceptive when it is
FEU – NRMF Institute of Medicine always use correctly and consistently
Department of Obstetrics and Gynecology CFR – pregnancy rates with various types of contraceptions at
different intervals or years. This is the number of pregnancies per
- Allows individuals and couples to anticipate and attain their 100 women at 1 year.
desired number of children and the spacing and timing of their PI – pregnancy rate computed at # of pregnancies x 1200 over
births woman months of use.
Permanent Method
- terminal
Methods of Contraception
Reversible Methods
• Spermicides
• Barriers
• Oral Contraceptive Pills
• Long Acting Hormonal Contraception
• IUD or IUS
Permanent
• Vasectomy
However, this is not locally available
• Bilateral Tubal Ligation
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BARRIER METHODS
DIAPHRAGM
• Needs fitting for the appropriate size
• Patient Instructions for insertion and removal
• Must cover cervical os totally
• Used with spermicide
• Left in place for 8 hours after last coitus
MALE CONDOM
• Latex, polyurethane, or animal tissue
• Most effective contraceptive method to prevent
transmission of STDs (latex, polyurethane)
• Males with multiple sex partners
• Correct use and careful removal
CERVICAL CAP
• Cup shaped rubber device fitted to the cervix
• Needs fitting (comes in 3 sizes)
• Used with spermicides
• Not left in place beyond 48h
• Failure rates similar to diaphragm
• Normal cervical cytology required
• Pap test three months after
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FEMALE CONDOM
• Loose fitting soft sheath with two polyurethane rings Calendar
• Inner and outer rings • If shortest cycle is 27 and longest cycle is 32, what is the
• Prelubricated woman’s fertile period?
• Single use only
COMPUTE
- One ring lies inside the vagina at the closed end of the sheath
and serves as an insertion mechanism and internal anchor. The 27-18=9 and 31-11= 20
outer ring forms the external edge of the device and remains
outside the vagina after insertion, thus providing protection to Fertile period is from days 9 to 20 and couple should abstain or
the labia and the base of the penis during intercourse. use barriers at this time
Barriers: Advantages
• Reduction of STD transmission especially if used with
spermicides
• Protection against salpingitis and cervical neoplasia
Periodic Abstinence
• Avoidance of coitus at the time ovum can be fertilized
• Highly motivated couple
• Four methods:
Calendar/Rhythm
Temperature
Cervical mucus method
Symptothermal
Calendar/Rhythm
• Fertile period based on length of cycles
• Shortest cycle subtract 18 and longest cycle subtract
11
• Couple abstains during the estimated fertile period
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Cervical Mucus/Billing’s method - Fixed- dose products consist of tablets containing both
• Recognition of changes in cervical mucus consistency an estrogen and progestin. In most formulations they
• Abstinence or barrier on the first day of copious slippery are given continuously for 3 weeks. No steroids are
mucus then the couple abstains daily until 4 days after given for the next 7 days
the last day when the characteristic mucus was - Without estrogenic stimulation the endometrium usually
observed. begins to slough 1 to 3 days after stopping steroid
• “wet” = ABSTAIN ingestion.
• “dry” = SAFE PERIOD
Combination phasic (multiphasic, biphasic, triphasic)
Symptothermal Method - 2-3 different dose of E +P
• Calendar + cervical mucus to establish first day of fertile - Tablets of same dose given for 5-11 days in the 21
period medication period
• Temperature method to establish last day - Not found to have advantage over fixed dose
Daily progestin/minipill
• low dose progestin
• taken daily at the same time
• no steroid free interval
• ideal for nursing mothers
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The magnitude of these effects is directly related to the dosage Reproductive Effects
and potency of the steroids in the formulations. • No permanent infertility
• HPO suppression is temporary and reversible
increased aldosterone synthesis and decreased sodium and fluid • Length of delay of return to fertility related to estrogen
excretion. dose and user age not duration of use
• Pregnancy immediately after discontinuation not
produce changes in mood and depression brought about by associated with higher abortion or anomaly rates
diversion of tryptophan metabolism from its minor pathway in the
brain to its major pathway in the liver. Neoplastic Effects
- Breast Cancer
- no significantly higher risk compared to never
• Progestin Component users
• androgenic effects (weight gain, acne, - Cervical Cancer
nervousness) - uncertain, conflicting evidences
• adverse mood changes and tiredness - Liver adenoma
• failure of withdrawal bleeding - high dose mestranol formulations
• irregular bleeding
• headaches - OCs have been extensively used for more than 35 years, and
Progestins are structurally related to testosterone hence can numerous epidemiologic studies of both cohort and case-control
cause androgenic effects design have been performed to determine the relation between
use of these agents and the development of various types of
Protein Metabolism Effects neoplasms.
• Increased hepatic globulin production (estrogen)
factors V,VIII, X, fibrinogen thrombosis
angiotensinogen BP elevation
CVS Effects Because oral contraceptive steroid formulations with more than
- Venous thromboembolism-risk is greater for higher 50mcg of estrogen were associated with a greater incidence of
doses (>50µg)of estrogen adverse effects without greater efficacy, they are no longer
- Myocardial infarction-no evidence of increased risk of marketed for contraceptive use in the United States, Canada,
MI from atherosclerosis and Great Britain. With the exception of women in whom
- Stroke-conflicting results, No increased risk for past users unusually rapid metabolism of synthetic steroids is anticipated
compared to never users (e.g., women on medications that induce the cytochrome P450
system), use of pills containing 50mcg of estrogen is not
recommended.
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Relative Contraindications
- Heavy smokers (<35 years old)
- Migraines
- Undiagnosed cause of amenorrhea
- Depression
- Prolactin-secreting macroadenomas
OCPS: Advantages
- Highly effective
- Readily available
- Affordable
Contraceptive Patch
- Easy administration
• 75g ethinyl estradiol + 6.0 mg norelgestromin
- Many non contraceptive health benefits
• One patch per week for three weeks followed by 1
week patch free
OCPS: Non contraceptive health benefits
• MOA similar to OCPs
• Endometrial cancer-protective
• Buttocks, upper outer arm, lower abdomen. Upper
• Ovarian cancer-protective
torso except breast
• Colorectal cancer-protective
Contraceptive Vaginal Ring
• Antiestrogenic effects of progestin
• Steroid delivery through vaginal mucosa directly into
• reduction of menstrual blood loss and less risk
circulation
for iron deficiency anemia
• 2.7 mg ethinyl estradiol and 11.7 mg etonorgestrel
• less incidence of menorrhagia, irregular
• Placed in vagina for 21 days followed by removal for 7
menses and intermenstrual bleeding
days then insertion of new ring
• less likely to develop endometrial adenoCA
• One size, no fitting
• reduction of incidence of benign breast
• MOA like OCPs
diseases
• Expulsion uncommon
• Inhibition of Ovulation
• less dysmenorrhea and premenstrual tension
Injectables
• protection against development of functional
Three formulations
ovarian cysts
1. DMPA
• reduction in size of functional ovarian cyst
2. Norethindrone enanthate
• protection vs ovarian cancer
3. Estrogen + progestin formulations
• Other Benefits
Injectables: DMPA
1. Risk reduction rheumatoid arthritis
• IM or subcutaneous preparations
2. Protection against PID
• Very effective reversible method
3. Reduction in incidence of ectopic pregnancy
• 3 MOAs
4. Reduction of bone loss -perimenopause
1. Inhibition of ovulation
2. Thinning of endometrium
Important Points in Prescribing OCPs
3. Cervical mucus changes
• Adolescent
• Given within the first 5 days of the cycle
• After pregnancy
• Nursing/breastfeeding mothers
Contraceptive implant
• Medical comorbidities (i.e DM, HPN, heart diseases)
• Progestin-only containing contraceptives
• Inserted subdermally under local anesthesia
OCP Users: Follow-up
• MOA same as injectables
• Lab test not necessary for healthy women
• Nondirected history and BP after 3 months
Advantages : DMPA and Implant
• Annual visits: BP, weight, complete PE, cytology
• No daily intake of pills
• Infrequent administration
• Maybe appropriate for those with contraindications to
estrogen
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BTL: Complications
• Bleeding
• Infection
• Anesthetic complications
• Bowel injury (laparoscopic electrocoagulation)
• Uterine perforation and device expulsion (microinserts)
• Permanent contraception
• Fallopian tubes, vas deferens
• Reversal are difficult, success rates variable
• Pregnancy rates: extent of damage, surgeon’s
expertise
Vasectomy
• Short outpatient procedure
• Local anesthesia
• Sterility after 14-20 ejaculations
• Two aspermic ejaculates required
Vasectomy: Complications
• Hematoma
• Sperm granulomas
• Spontaneous reanastomosis
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GYNE- Family Planning 2017
This slide will tell us what are the most effective and the least
effective at a glance.
DISCUSSED:
Discuss different family planning methods as to:
✔ Types
✔ Preparations
✔ Mechanism of actions
✔ Effectivity
✔ How to use
✔ Advantages and disadvantages
✔ Adverse effects