Contraception: I. Non-Hormonal Methods

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1 Contraception: I. Non-Hormonal Methods Prof. Karim Hassanein I. Abd- El-Maeboud OB/GYN Department Ain Shams University

2 Family Planning A Branch of Reproductive Health Service (RHS). Def.: In advance regulation of family size. Family Planning Contraception (reversible) Sterilization (permanent) Management of Infertility Management of Recurrent Abortion Management of Rec. Fetal Anomalies (Genetic Counseling)

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4 Contraception: Effectiveness Rate The Perfect use rate The Typical use rate

5 Contraception Methods Traditional (Folklore) Methods Non-Hormonal Hormonal LAM OCs Periodic Abstinence Subdermal Implants Coitus Interruptus Injectables Barrier Vaginal rings IUD (non-hormone releasing) IUDs (hormone-releasing) releasing)

6 Celibacy (Is this contraception, or non-participation?)

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8 Lactational Amenorrhea Method (LAM) Useful: Temporary Postpartum Contraception within first 6 Months after delivery + Still Amenorrhea + ~ (>85%) Fully breastfeeding. Effectiveness: >98% Expiring of any criterion (esp. Amenorrhea), must use another method.

9 Lactational Amenorrhea Method (LAM) Mechanism of action: Breast : Suckling Stim. Nipples Hypothalamus : Prolactin + Disrupted GnRH Pituitary : Release FSH & LH Ovary: : Ovulation (ANOVULATION)

10 Lactational Amenorrhea Method (LAM) ADVANATAGES 1. Availability: Universal 2. No commodies, supplies, or additional cost. 3. Onset: immediately postp. 4. Effectiveness: 98% in wellselected. 5. Health Benefits: Mother/infant 6. Temporary till deciding other method. DISADVANTAGES 1. Only Temporary for lactating. 2. ~Full Breast feeding? Social. 3. Duration: Limited 4. Effectiveness: Lower 5. No STI or HIV protection. Other Contraceptive Options for Breastfeeding Women

11 LAM Algorithm Have your Menses returned? NO Regular supplement or long periods without breast feeding? NO Is your baby more than 6 months? YES YES YES Begin another method of contraception Maintain breastfeeding for infant health NO No additional contraception necessary only LAM

12 Coitus Interruptus (Withdrawal M.) During intercourse: penis is withdrawn from vagina before ejaculation so as to prevent العزل ovum. contact between sperm & ADVANTAGES 1. Availability: universal. 2. No financial cost DISADVANTAGES 1. Efficacy: failure 4-18% 1 st Y. (self control, pre-ejaculatory secretions) 2. Interference with sexual intercourse: correct & consistent high self-control +?adverse emotional impact to ½ 3. No protection from STIs/HIV

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15 Periodic Abstinence Abstaining from intercourse during a woman s fertile time Methods to identify fertile phase of menstrual cycle Calendar (Rhythm) M.: Luteal phase 14±2 days Basal Body Temperature (BBT) M.: Biphasic in ovulatory cycle Cervical Mucus M.: E vs P effect on appearance & texture Symptothermal M.: Combined BBT + Mucus ± other ovulatory Signs (e.g. breast tenderness, back pain, abdominal discomfort

16 Periodic Abstinence Calendar (Rhythm) M.: Luteal phase 14±2 days

17 Periodic Abstinence Calendar (Rhythm) M.: Luteal phase 14±2 days Shortest Cycle 18 Longest Cycle -11

18 Periodic Abstinence Basal Body Temperature (BBT) M.: Biphasic in ovulatory cycle

19 Periodic Abstinence Cervical Mucus M.: E vs P effect on appearance & texture

20 Periodic Abstinence Symptothermal M.: Combined BBT + Mucus ± other ovulatory Signs (e.g. breast tenderness, back pain, abdominal discomfort

21 Periodic Abstinence ADVANTAGES 1. Availability: readily 2. No financial cost 3. User controlled 4. Free from side effects. DISADVANTAGES 1. Requires: skill, motivation & partner s cooperation 2. Fertility signs may not be reliable 3. Failure rates: relatively high. 4. No STIs/HIV protection

22 Barrier Methods: General Mechanism: Physical or Chemical blockage to the passage of sperms into vagina or cervical canal. ALL ARE: Client-dependent: Motivation + Skill + Partners Communication Correct + Consistent use Effective

23 Barrier Methods: General ADVANTAGES 1. Initiate & discontinue: Easy. 2. Not need clinic visit (except for Diaphragm & cx. Cap). 3. Safety: relatively. No systemic side effects. 4. Return of fertility after Discontinuation: Immediate. 5. Preventing STDs & HIV (condom). DISADVANTAGES 1. Effectiveness: less than other modern m. 2. Application: Difficulties as consistent, correct, cooperation, interruption of sexual act. 3. Re-supply (cost) 4. Proper storage to maintain quality.

24 Barrier M.: 1. Male Condom Made of: Latex rubber. Most widely used Barrier. Failure Rate: 3 14% (decrease + spermicidal use) ADVANTAGES: 1. Effectiveness: Satisfactory. 2. Availability: Wide. 3. Protection: STDs, VIH 4. Coital for male (potency, premature ejaculation). DISADVANTAGES: 1. Interferes with sexual pleasure. 2. Damage: exposure to oilbased lubricant, heat, light, humidity. 3. Disposal in poor country.

25 Barrier M.: 2. Vaginal Diaphragm Dome shaped Device. Dome (molded of a thin layer of latex) with a circular edge (ring is rubber-covered spring). Different sizes (50-95mm diameter). Dual mechanism: Physical + Spermicidal (more Effective) Dependence of success on couple behavior: Proper usage 3 pregnancy/100 women year.

26 Barrier M.: 2. Vaginal Diaphragm Details of Insertion: 1. When? Up to 6 hs. before coitus. 2. Where? In upper vagina opposite cervix. 3. How? Lubricate (vaginal cream/jelly), Squeeze, Insert, Release (resumes original shape & fits obliquely in vagina covering cervix).

27 Barrier M.: 2. Vaginal Diaphragm Details of Removal: When? 6 hs. After intercourse + vaginal Douching only after removal. ADVANTAGES 1. Reusable (after cleansing) 2. Insertion ahead (<6hs) from the act. 3. Some protection against bacterial STDs (with spermicide usage) DISADVANTAGES 1. Demands learning of proper insertion by health care provider 2. Messy intercourse. 3. Delayed removal 4. May irritation or UTI

28 Barrier M.: 3. Spermicides Surface active detergent. Active ingredient mostly: NONOXYNOL-9 Mechanism: Inactivates or immobilizes sperms Effectiveness: much less than other modern m. Can increase UTI in women Protection modest against bacterial STDs.

29 Barrier M.: 3. Spermicides Different Pharmaceutical Forms: Aerosol foams Foaming tablets Cream jelly suppository.

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31 Barrier M.: 4. Female Condom (Vaginal Pouch) Polyurethane: Tubing ~8 cm diameter & 17 cm long + flexible rings at each end: Closed end adaped deep into vagina, and other large end covering vulva & perineal skin. Effective: when correct & consistent use. Protection: bacterial &?viral STDs.

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33 Barrier M.: 5. Cervical Cap Cup-shaped device, inserted directly onto cervix before coitus Different size: 4 diameters 22-31mm Difficult to achieve proper fitting. Difficult to learn insertion technique. Difficult application to Deformed (abn. Shape) cx Failure Rate: proper use Nullip: as diaphragm; parous: much higher.

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35 Barrier M.: 6. Vaginal Sponge

36 Barrier M.: Dual Method Use Condom: pregnancy + STDs Failure to use, rupture, slipping = Emergency contraception as a back-up for pregn not STD. Highly effective method (Iry for pregnancy) + Condom (for STDs).

37 Intra-uterine Contraceptive Device (IUCDs or IUDs) Flexible polyurethane plastic devices inserted into uterine cavity.

38 Intra-uterine Contraceptive Device (IUCDs or IUDs) Types: All with monofilament plastic tail: FU & removal Non-medicated (Inert) IUDs: Lippes Loop, China Medicated IUDs Copper-releasing Hormone-releasing (Mirena or Progestasert) TCu 380A: one of most widely used worldwide:wire+bands Multiload: wings e protrusions + Cu wire on vertical stem Nova-T (Novagard): silver-cored Cu wire around stem

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41 Intra-uterine Contraceptive Device (IUCDs or IUDs) Mechanism of action: Interferes with 1. Sperm passage: cx mucus, ut cavity, t fluid. 2. Ovum transport & viability: Altered ut+t fluid 3. Fertilization 4. Endometrium (local endom. Foreign body reaction: increased prostaglandin, leucocyte infiltration: Hostile to sperm &?to ovum). NO EFFECT on Ovulation/Steroidogenesis

42 Intra-uterine Contraceptive Device (IUCDs or IUDs) Advantages of Cu IUD 1. Safe (No systematic side effects + rare complications) 2. Used by Breastfeeding w. 3. Highly Effective (>99%). Failure rate 1-2/HWY. 4. Easy to use (no action at coitus) 5. Long acting (TCu380A 10Y.) 6. Easy reversible (gentle pulling on threads by HCP) with rapid return of fertility. Disadvantages 1. Trained HCP by insertion & removal 2. No protection STDs. 3. Not recommended for women at risk of STDs. 4. Can cause Side Effects (common first few months after insertion): Dysmenorrhea (abd. Cramps) Menorrhagia. Intermenstrual bleeding.

43 Intra-uterine Contraceptive Device (IUCDs or IUDs): Complications PID Slightly increased risk in 1 st Month after insertion (d.t. introduction of bacteria into uterine cavity from LGT). Prevention: 1. Screen potential users (s & s) of current STDs & assess their risk. 2. Aseptic technique during insertion.

44 Intra-uterine Contraceptive Device (IUCDs or IUDs): Complications Perforation Rare, yet potentially serious. Risk: linked to skill & experience of provider (training decrease incidence) Risk: linked to postpartum timing: increased in insertions between 48 hs to 4 weeks after delivery (Avoid This: either <48hs, or >4 weeks).

45 Intra-uterine Contraceptive Device (IUCDs or IUDs): Complications Expulsion Partial or Unnoticed Expulsion: irregular bleeding, pain, and/or pregnancy. Risk Factors: providor s skill, woman s young age, nulliparity, repeated colics, insertion timing, time-interval after insertion.

46 Intra-uterine Contraceptive Device (IUCDs or IUDs): Complications Pregnancy Ectopic: In pregnant IUD user, Risk is higher compared to other methods (Incidence ~2/10000 users = 1/30 pregn). Intra-uterine: Perforation, displacement, expulsion. IUD user with amenorrhea??!!!

47 Intra-uterine Contraceptive Device (IUCDs or IUDs) Warning Symptoms 1. Threads: Not Felt or Hard Plastic felt. 2. Complete Expulsion. 3. Vaginal: Purulent discharge 4. Vaginal: Heavy persistent bleeding 5. Amenorrhea. 6. Lower abdominal: Pain 7. General Symptoms: Fever, malaise.

48 1. LOST STRINGS If an IUD user is unable to palpate the IUD strings, a speculum exam should be performed. If the strings are not seen in the cervical os, the device 1. May have been expelled, 2. May have perforated the uterine wall, or 3. The strings may have been drawn up into the cervical canal. 4. Short threads or Fragmented IUD.

49 1. LOST STRINGS Pregnancy should be excluded. Once pregnancy is excluded, the cervical canal should be explored (with a cotton swab, forceps, or similar instrument) to see if the strings can be found.

50 1. LOST STRINGS If the strings cannot be found, ultrasound is the preferred method to identify the location of the IUD. If the device is seen within the uterus, it can be left in situ.

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52 1. LOST STRINGS If the device is not identified within the uterus or the pelvis, a plain x-ray of the abdomen should be performed to determine whether the device has perforated the uterine wall. Both the LNG-IUS and the copper IUD are radio-opaque.

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56 2. PREGNANCY WITH AN IUD IN PLACE Once she get pregnant, the diagnosis of an ectopic pregnancy has been excluded, The IUD should be removed if possible. If the strings are visible, gentle traction is applied to remove the device. If the strings are not visible, gentle exploration of the cervical canal is performed.

57 2. PREGNANCY WITH AN IUD IN PLACE If no strings are found, the possibility of perforation must be considered. Expulsion? This is best excluded by pelvic ultrasound. Note should be made of recovery of the IUD at the time of delivery.

58 Intra-uterine Contraceptive Device (IUCDs or IUDs) Timing of Insertion Interval insertion: 1. During or immediately after menses. 2. Anytime in cycle if definite proof not pregnant. Postpartum insertion: Up to 6 weeks after delivery or 4 6 weeks after abortion.

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63 Ideal candidate for IUD 1. A parous woman 2. In a stable, mutually monogamous relationship, 3. With no history of PID.

64 Intra-uterine Contraceptive Device (IUCDs or IUDs) CONTRAINDICATIONS 1. Copper allergy or Wilson s disease (rare) 2. Distorted uterine cavity (e.g. subseptate). 3. Pregnancy or suspicion thereof or previous ectopic pregnancy. 4. Unexplained vaginal bleeding. 5. Current anticoagulant therapy. 6. Cancer: Cervix, endometrium, or ovary. 7. Valvular heart disease (? SABE) 8. GT Infection: Current PID, STDs or purulent cervicitis Infection following delivery or abortion. Pelvic TB High risk factors for PID Immunosuppressant (e.g.. systemic corticosteroids)

65 MYTHS AND MISCONCEPTIONS 1. Nulliparous women cannot use IUDs. 2. IUDs increase the risk of ectopic pregnancy. 3. IUDs increase the risk of infertility. 4. IUDs increase the long-term risk of PID. 5. IUDs are not effective contraceptives.

66 MYTHS AND MISCONCEPTIONS Nulliparous women cannot use IUDs. Fact: Nulliparity is not a contraindication to IUD use. In carefully selected nulliparous women, IUDs may be successfully used.

67 MYTHS AND MISCONCEPTIONS IUDs increase the risk of ectopic pregnancy. Fact: IUDs do not increase the risk of ectopic pregnancy. Because IUDs work primarily by preventing fertilization, IUD users have a lower risk of ectopic pregnancy than women who are not using any form of birth control ( /100 WY versus /100 WY). However, in women who conceive with an IUD in place, the diagnosis of ectopic pregnancy should be excluded.

68 MYTHS AND MISCONCEPTIONS IUDs increase the risk of infertility. Fact: IUDs do not increase the risk of infertility. Women who discontinue use of an IUD in order to conceive are able to conceive at the same rate as women who have never used an IUD. Copper IUD use is not associated with an increase in tubal factor infertility in nulliparous women.

69 MYTHS AND MISCONCEPTIONS IUDs increase the long-term risk of PID. Fact: The incidence of PID among IUD users is less than 2 episodes per 1000 years of use, similar to that of the general population. The increase in risk of PID associated with IUD use appears to be related only to the insertion process. After the first month of use, the risk of infection is not significantly higher than in women without IUDs.

70 MYTHS AND MISCONCEPTIONS IUDs are not effective contraceptives. Fact: IUDs are a highly effective method of birth control. In fact, in long-term users of IUDs, the failure rate approaches that of tubal ligation. The LNG-IUS appears to be as effective as tubal ligation.

71 OLD versus NEW

72 Hormone-Releasing Intrauterine System (IUS) The most recent form of IUD It is a newer form of hormonal contraception. It has a T shape. It contains progestin that is released directly into the uterus. It is not a substitute for copper-bearing IUDs. It can be used if a woman has excessive bleeding with a copper IUD (+cannot tolerate + still wants IUD & can afford a high price of hormone-releasing IUD: Counsel she will be using a hormonal rather than a non-hormonal method: Rule out contraindications to IUD and progestin prior to initiaition). It is more expensive than other types of IUD

73 Types: Progestarsert: life span 1 year. Mirena (Levonorgestrel-releasing system): 5 ys. Mechanism of action: In addition to general mechanisms: Physical characteritics (Thickening) of cervical mucus changes and becomes impermeable to sperms (as well as to harmful microorganisms, therefore limiting ascending infection. Partial suppression of ovulation Hormone-Releasing Intrauterine System (IUS)

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75 Hormone-Releasing Intrauterine System (IUS) ADVANTAGES: General advantages of IUD (Safe & Highly effective easy to use, no action needed at time of sexual intercourse or any other time, long-acting (5 ys) but reversible) Non-contraceptive health benefits: reducing the duration & quantity of menstrual bleeding and pain Possibly provides protection from PID. DISADVANTAGES: General disadvantages of IUD (Providor s help needed to initiate or discontinue) Side effects: irregular bleeding and spotting are common No protection from STDs including HIV. + more expensive + not available in many countries.