Older (2nd generation) – Norethisterone (Norethindrone) & Levonorgestrel Newer(3rd generation) – Desogestrel, Gestodene & Norgestimate (Noregestromin) Latest (derived from Spironolactone) - Drospirenone

Start 1st packet 1st day of a menstrual period Take 21 pills and stop for 7 day break (PFI) Restart each new packet on 8th day (same) Do not start new packets late If late or missed pills in 1st 7 days, condoms If missed pills in last 7 days no PFI

Contraception Flashcards by Rorleen Matemba

Perfect contraception

100% Reliable
100% Safe
Non User Dependent
Unrelated to Coitus
Visible to the Woman
No ongoing Medical Input
Completely reversible within 24 hours
No Discomfort

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Methods which require ongoing action by the individual

Oral contraception
Barrier methods
Fertility awareness 
Coitus Interrupts 
Oral emergency  contraception

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Methods which prevent conception by default

IUCD/IUI/IUS
Progestogen Implants
Progestogen Injections
Sterilisation

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Risk of treatment

Cardiovascular 
Neoplastic 
Emotional 
Infection related 
Allergic 
Iatrogenic

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Risk of no treatment

Childbirth related
Abortion related
Social costs
Economic costs

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Benefits of treatment

Non contraception 
Psychosexual 
Choice
Sexual health
Cost savings
Female equality

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Benefits of no treatments

Non interference
Population growth
Control of women

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Progestogens

Older (2nd generation) – Norethisterone (Norethindrone) & Levonorgestrel
Newer(3rd generation) – Desogestrel, Gestodene & Norgestimate (Noregestromin)
Latest (derived from Spironolactone) - Drospirenone

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How does oestrogen work

On anterior pituitary & hypothalamus
Directly on the ovary
On the Endometrium

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How does progestogen work?

On anterior pituitary & hypothalamus
Directly on the ovary
On the Endometrium
On the fallopian tubes
On cervical mucus

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Combined oral contraception - benefits

1. Contraception 
•	Reliable
•	Safe
•	Unrelated to coitus
•	Woman in control
•	Rapidly reversible

Non contraception
• Halve ca ovary
• Halve ca endometrium
• Helps endometriosis, menorrhagia, dysmenorrhoea

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Risks

Cardiovascular - Arterial - Progestogen , HBP, smoking
Venous - Oestrogen-VTE-clotting disorders (DVT, PE, Migraine)
Neoplastic - Breast cervix, liver
Gastrointestinal -COH/insulin metabolism, Weight gain, Crohns disease
Hepatic - hormone metabolisms, congenital nonhaemolytic jaundices, gall stones
Dermatological - Chloasma, acne, erythema multiforme
Psychological - Mood swings, depression, Libido

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Pill rules

Start 1st packet 1st day of a menstrual period
Take 21 pills and stop for 7 day break (PFI)
Restart each new packet on 8th day (same)
Do not start new packets late
If late or missed pills in 1st 7 days, condoms
If missed pills in last 7 days no PFI

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Interacting medication

Liver enzyme inducing drugs - see list/MIMS

Affect metabolising of both oestrogen and progestogen
Beware rifampicin and anti-epileptics
1. Broad spectrum antibiotics
Affect enterohepatic circulation of oestrogen only (40%)

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Combined vaginal contraceptive

Same as COCP except vaginal delivery (ring) for 21 days
Remove for 7 days
Advantage – don’t have to take every day
Disadvantage - don’t have to take every day!!

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Progestogen only methods

Default Methods
Implants:  Nexplanon  Norplant (LNG)
Hormone releasing IUCD:
 Mirena IUS (LNG)
Default Methods
Implants:  Nexplanon  Norplant (LNG)
Hormone releasing IUCD:
 Mirena IUS (LNG)

Why cerelle is better than older POPs

As effective as COCP
No oestrogen – CIs e.g. breastfeeding
Favourable side effect profile vs older POPS
Bleeding as predictable as COCP
12 hour window

IUDCs

Copper bearing intrauterine contraceptive devices are inserted into the uterus by suitably trained practitioners and may be left in situ long term and act by
1. Destroying spermatozoa
2. Preventing implantation – Inflammatory reaction and prostaglandin secretion as well as a mechanical effect.
All IUCDs can be left in situ for 5 years whatever the makers inserts say. Any device inserted after the 40th birthday could be left in until after the menopause if the woman wishes without being replaced

Benefits of IUDCs

Non user dependent
Immediately and retrospectively effective
Immediately reversible
Can be used long term
Extremely reliable
Unrelated to coitus
Free from serious medical dangers

Disadvantages of IUDCs

Has to be fitted by trained medical personnel
Fitting may cause pain or discomfort
Periods may become heavier & painful
It does not offer protection against infection
Threads may be felt by the male

Risks

Miscarriage if left in situ if a pregnancy
ectopics
May be expelled
The uterus may be perforated
Removal in the early weeks before the threads are lost is unlikely to result in miscarriage
It protects against all forms of pregnancy, but less well against ectopics
Infection may be introduced at insertion (max at 3/52), but it does not increase likelihood of “catching” infection or make PID worse if left in situ. Careful sexual history is best guide here.
Expulsion more likely in 1st 3/12. Perforation is 1/1000 insertions

Absolute contraindications for IUCDs

Current pelvic inflammatory disease
Suspected or known pregnancy
Unexplained vaginal bleeding
Abnormalities of the uterine cavity

Relative containdications

Nulliparity
Past history of pelvic inflammatory disease
Not in mutually monogamous relationship
Menorrhagia / Dysmenorrhoea
Small uterine fibroids

Condoms Male Advantages

Man in control
Protects against STIs
No serious health risks
Easily available (free at family planning clinics)

Condom Female Advantage

Woman in Control Protects against STIs Can be put in advance and left inside after erection lost Not dependent on male erection to work

Disadvantages of condoms (male)

``` Last minute use Needs to be taught May cause allergies May cause psychosexual difficulties Higher failure rate among some couples Oil preparations rot rubber ```

Disadvantages of condoms (female)

``` Obstrusive Expensive Messy Rustles during sex Uncertain failure rate ```

Caps -Diaphragm

Made of latex Fit across vagina Sizes 55 – 95 mmin 5 cm jumps Must be used with spermicide and left in at least 6 hours after sexual intercourse

Caps - Suction (cervical)

Suitable for women with poor pelvic muscles No problems with rubber allergies Very unobtrusive Woman in control

Disadvantages of diaphragm caps

Needs to be taught Messy Higher failure rate than most other methods Higher UTI Higher Candiasis

Disadvantages of Suction caps

Needs an accessible and suitable cervix Higher failure rate than diaphragm Not easy to find experienced teacher

Fertility awareness

* Prediction of ovulation ? 14/7 before period * Sperm can survive 5 days in female tract * Ova can survive 24 hours * Ova are fertilised in the fallopian tube and take 4 days to reach the uterus and implant * Cervical mucus is receptive to sperm around the time of ovulation * Use Periodic Abstinence/alternative contraception to avoid pregnancy * Time intercourse to pre-ovulatory phase to conceive

Natural family planning

* Temperature * Rhythm * Cervix position * Cervical mucus * Persona * Lactational amenorrhoea (LAM)

Fertility Awareness - advantages

Non medical Can be used in 3rd world Allowed by Catholic church • Can result in closeness of understanding between partners

Fertility Awareness - disadvantage

Failure rate heavily user dependent Requires skilled teaching May require cooperation between partners May involve limiting sexual activity Can cause strain

Emergency contraception

• Postcoital Pills • Up to 72 hours after unprotected sexual intercourse (UPSI) • Schering PC4 – prevents 3 out of 4 pregnancies which would have occurred • Levonelle – prevents 7 out of 8 pregnancies • ellaOne (ulipristal)– similar • Copper bearing IUCDs • Up to 5 days after presumed ovulation or 5 days after one single episode of UPSI at any time of the cycle • Failure extremely rare Not abortion. The law of the land defines implantation as the time of pregnancy and takes the view that you cannot have abortion if there was no pregnancy (no miscarriage without carriage)

PC4

* Lower failure rate in 1st 24 hours. * Causes nausea & vomiting in many women • Contraindicated during focal Migraine attack

Levonelle 2

* Lower failure rate in 1st 24 hours * Very little nausea * Only contraindicated in women taking very potent liver enzyme medication (anti TB)

Postcoital contraception

Catholic women may be concerned that at blastocyst is not “killed” if they believe that life begins with fertilisation rather than implantation. The best evidence for pills is that they prevent or post pone ovulation. The evidence that they work at or after ovulation is less good. It may be that women in the second half of the cycle are unlikely to conceive. It may be worth explaining to women at mid cycle that an IUCD may be more reliable at this time.