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

Oral Contraception Vaginal contraception Barrier Methods Fertility awareness Coitus interruptus Oral Emergency contraception

IUD Progesterone implant/IUS/injection Male Sterilisation Female sterilisation

Oestrogen EthinylOestradiol - 20,30,35,50 micrograms (synthetic oestrogen) Progestogens Older (2nd generation) – Norethisterone (Norethindrone) & Levonorgestrel Newer(3rd generation) – Desogestrel, Gestodene & Norgestimate (Noregestromin) Latest (derived from Spironolactone) - Drospirenone Oestrogens act On anterior pituitary & hypothalamus On the Endometrium Progestogens act On anterior pituitary & hypothalamus On the Endometrium On the fallopian tubes On cervical mucus

Supra-physiological levels “Pseudo-pregnancy” Suppression of the HPO axis In reality: pharmacokinetics highly variable Individual serum levels vary Suppression may not be absolute Follicular activity possible in some Breakthrough bleeding in some

Reliable Safe Unrelated to coitus Woman in control Rapidly reversible Halve cancer ovary Halve cancer endometrium Helps endometriosis, premenstrual syndrome, dysmenorrhoea, menorrhagia Can stop periods if taken continuously

Cardiovascular - Arterial – Progestogen , HBP, smoking (>35) - Venous – Oestrogen-VTE-clotting disorders (DVT, PE, Migraine) Neoplastic - Breast?, Cervix?, Liver Gastrointestinal – COH/insulin metabolism, Weight gain, Hepatic – hormone metabolisms, congenital non-haemolytic jaundices, gall stones Dermatological – Chloasma, acne, erythema multiforme Psychological – Mood swings, depression, Libido

Contraindications Breast cancer; undiagnosed genital bleeding; pregnancy; <3 weeks post partum; breast feeding; hypertension; PH thrombosis; migraine with aura; active liver disease; thrombophilia; systemic lupus erythematosus; thrombotic thrombocytopenic purpura; smoking and age >35 Relative contraindications: BMI>35;migraine without aura; hypertension; diabetes – better alternatives!!

Griseofulvin Barbiturates Lamogitrine Topiramate Carbamazepine Oxcarbazepine Phenytoin Primidone Rifampicin Modafinil Certain antiretrovirals

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 Annual BMI and BP

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

Default Methods Implants: Nexplanon (ETN) Norplant (LNG) Hormone releasing IUCD: Mirena IUS (LNG) User Dependent Methods POPs - Desogestrel (Cerazette / Cerelle) - Norethisterone - Ethynodiol diacetate - Levonorgestrel - Norgestrel Injectables - Depo Provera (MPA) (12weekly) - Noristerat (NET)

Delivery method is user choice Systemic side effects (e.g. headache / bloating / acne) depend upon systemic absorption Effect on cervical mucous and endometrium highly reliable Effect on HPO suppression less reliable – some women ovulate! Irregular bleeding is potential issue for ALL methods

Why Desogestrel is taking over the world: As effective as COCP No oestrogen – CIs e.g. breastfeeding Favourable side effect profile vs older POPS Bleeding as predictable as COCP – probably not quite as good!! 12 hour window

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 • Destroying spermatozoa • Preventing implantation – Inflammatory reaction and prostaglandin secretion as well as a mechanical effect. • Copper bearing Ortho T 380 – 8 -12yr Multiload 375 – 5yr Multiload 250 – 5yr (Standard & Short) Nova T 380 – 5yr Nova T 200 – 5yr GyneFix (IUI) – 5yr Hormone bearing Mirena (IUS) – 5yr Jaydess – 3 years

Benefits: 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: Has to be fitted by trained medical personnel Fitting may cause pain or discomfort Periods may become heavier & painful – what have they just stopped using??? It does not offer protection against infection Threads may be felt by the male Risks: May be expelled The uterus may be perforated – very rare Miscarriage if left in situ if a pregnancy ? ectopics Absolute contrainidications: Current pelvic inflammatory disease Suspected or known pregnancy Unexplained vaginal bleeding Abnormalities of the uterine cavity Relative contraindications: Nulliparity Past history of pelvic inflammatory disease Not in mutually monogamous relationship Menorrhagia / Dysmenorrhoea Small uterine fibroids

Male Man in control Protects against STIs No serious health risks Easily available (free at Family Planning clinics) Female Woman in control Protects against STIs Can be put in in advance and left inside after erection lost Not dependent on male erection to work Disadvantages: Male Last minute use Needs to be taught May cause allergies May cause psycho sexual difficulties Higher failure rate among some couples Oily preparations rot rubber Female Female Obtrusive Expensive Messy Rustles during sex Uncertain failure rate

Diaphragm Caps Made of latex Fit across vagina Sizes 55 – 95mm in 5mm jumps Must be used with spermicide and left in at least 6 hours after sexual intercourse Advantages:Woman in Control Can be put in in advance Offers protection against cervical dysplasias Perceived as “natural” Disadvantages: Needs to be taught Messy Higher failure rate than most other methods Higher UTI Higher Candiasis Suction (cervical) Caps Made of plastic Suction to cervix or vaginal vault Different sizes Must be used with spermicide and left in 6 hours or more. Advantages: Suitable for women with poor pelvic muscles No problems with rubber allergies Very unobtrusive Woman in control Disadvantages: Needs an accessible and suitable cervix Higher failure rate than diaphragm Not easy to find experienced teacher

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

Advantages Non medical Can be used in 3rd world Allowed by Catholic church Can result in closeness of understanding between partners Disadvantages Failure rate heavily user dependent Requires skilled teaching May require cooperation between partners May involve limiting sexual activity Can cause strain

Postcoital Pills Levonelle 2 consists of 2 tablets each containing 750 micrograms of Levonorgestrel 1.5mg one dose Up to 72 hours after unprotected sexual intercourse (UPSI) Act by postponing ovulation in 1st part of the cycle – So beware! ??Act by preventing implantation in 2nd part of the cycle 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 Copper kills sperm in 1st part of the cycle Device prevents implantation in 2nd part of the cycle

PC4 PC4 (no longer available but people self administer!!!) 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) ellaOne ellaOne – ullipristal acetate New selective progestagen receptor modulator (SPeRM) Up to 120 hours Similar rates of pregnancy vs Levonelle Possible slightly higher side effect profile – GI symptoms mainly

Levonelle 2 Up to 24hrs – 95% 25 – 48 hrs - 85% 49 – 72 hrs- 58% Schering PC4 Up to 24 hrs – 77% 25 – 48 hrs – 36% 49 – 72 hrs – 31%