Hormonal Contraception/IUCD

Hormonal contraceptives
Used for reversible suppression of fertility

Oral contraceptives:
-Efficacious
-Cost-effective
-Overall safety
-Complete return of fertility on discontinuation
1. Oral contraceptives
Combined pill: efficacy 98-99.9%
Estrogen + progestin
2nd generation pills- decreased estrogen
+progestin
3rd generation pills- newer progestins
-desogestrel
COURSE:
1 tablet daily (starting on 5th day of menstruation)- 21
days

Next course after gap of 7 days

2. Phased regimens
Reduction in total steroid dose without compromising
efficacy
-Biphasic
-Triphasic
Estrogen: constant( or varied between 30-40
micrograms)
Progestin: low in the first phase. Progressively higher in
the 2nd and 3rd phases
Medical eligibility criteria (WHO)
Category 1: (No restriction of use)
1. Menarche to 40 years
2. Postpartum > 21 days, post-abortion
3. Endometriosis, fibroid
4. Iron deficiency anaemia
Category 2 ( benefits outweigh the risk)
1. Age over 40
2. Obesity
3. Migraine
4. Valvular heart disease
5. Diabetes
6. Hyperlipidemias
Category 3 (risk outweigh benefits)
1. Cigarette smoking <15/ day in > 35 years
2. Postpartum <21 days
3. Cholestatic jaundice
4. Hypertriglyceridemia
Category 4 (not to be used)
1. Stroke and CAD
2. Hypertension (SBP >160 and DBP>100)
3. Thrombotic patients
4. Suspected pregnancy
5. Breast cancer
6. Hypersensitivity to any component of the pill
Contraindications:
Arterial thrombosis
Venous thrombosis
Valvular heart disease
Ischemic heart disease
Previous CVA and brain vasular malformation
Uncontrolled hypertension
Focal and crescendo migraine
Liver diseases, tumours, gallstones
Pregnancy
Porphyria
Oestrogen-dependent neoplasia
Undiagnosed genital tract bleeding
Conditions affected by steroid use e.g hydatiform mole (unless the
serum HCG is normal)

Relative contraindactions:
Obesity
Increasing age
Diabetes mellitus (low dose pills can be used)
Hyperprolactinaemia
Smoking (they should be advised to stop)
Side effects:
Oestrogenic Progestogenic
Nausea Depression
Headaches “Premenstrual tension”
Increased mucous Irregular bleeding
Fluid retention and weight Acne
gain
Increased blood pressure Breast discomfort
Bleeding Weight gain
Cervical ectoprion Reduced libido
Chloasma
Suppression of lactation
Non-contraceptional benefits
Improvement in menstrual abnormalities
Protection against cancer
Protection against health diseases
Progesterone only (Minipill)

Considered a “poor relative” of the combined OCP

Low dose Progestin only pill
Several peparations available ( 350 microgram
norethisterone and 75 microgram norgestrel commonly
used)
Taken continuously without any gap (considered missed if
3 hour delay in usage occurs)
Indication of use:
- Usually prescribed to women who have contraindications to
use of estrogen-containing OCP e.g migraines,
cardiovascular and thromboembolic risks, nursing mothers.
Mechanism of action:
Thickening of cervical mucus affecting sperm
permeability
Inhibition of ovulation (40% of women)
Endometrium becomes unresponsive to ovulation
(thinning of endometrium)
Variable effect on fallopian tube epithelium (decreased
tubal motility and slowed ovum transport)
Contraindications:
Previous ectopic pregnancy
Functional ovarian cysts
Severe liver disease
Severe arterial disease
Undiagnosed vaginal bleeding
Recent molar pregnancy
Pregnancy
Breast cancer
Side effects:
Irregular bleeding (most common)
Persistent ovarian follicles (follicular cysts)
Bloating
Weight gain
Headache
Nausea
Skin changes
Efficacy:
Failure rate is 0.5 per 100 women years if used
correctly.
However, in practice usual failure rate is 3.
Post coital (emergency) contraception

WHO (1998):
Emergency contraception can be provided using:
1. Emergency contraceptive pills (ECPs)- to be used
with 72 hours post coitus
2. Intrauterine devices (IUDs)- inserted within 5 days
and used as long term method. Failure rate of 1%.
Mechanism of action:
1. Ovulation inhibited or delayed
2. Alterations of endometrial receptivity for
implantation
3. Dislodges in an implanted blastocyst
4. Production of cervical mucous that decreases sperm
penetration
5. Alterations in tubal transport of sperm, egg and
embryo.
3 regimens:
a. Levonorgestrel 0.5 mg + ethinylestradiol 0.1 mg
 within 72 hrs and repeated 12 hrs
 ‘YUZPE method’
 Failure rate of up to 7%
b. Levonorgestrel 0.75 mg (Postinor)
 twice with 12 hr gap within 72 hrs
 WHO essential drug list (2001)- recommended
replacement of YUZPE method by this regimen
 Single dose treatment also available.
c. Mifepristone 600 mg
single dose with 72 hrs
Commonly referred to as “the abortion pill”
It is an antiprogesterone

To note: Recently approved in 2010, ULI

Injectable
-obviate need for daily ingestion of pills
 given i.m as an oily solution
 highly effective
a. Long acting progestin alone:
injected once in 2-3 months depending on steroid
and its amount
b. Depot medroxyprogesterone acetate (DMPA)
150mg at 3 month intervals
With regular
c. Norethindrone (norethisterone) enthanate (NNE)
200mg at 2 month intervals
c. Long acting progestins + long acting estrogens
once a month
MPA + estradiol cypionate- approved by US-FDA
Male contraceptive
Inhibits spermatogenesis
Complete suppression of spermatogenesis is relatively
difficult without affecting other tissues
Spermatogenesis takes 64 days
Drugs
Antiandrogens
Estrogens and progestins
Cytoxic drugs- cadmium, nitrofurans
Gossypol- nonsteroidal compound obtained from
cotton seed. It suppresses spermatogenesis in 99% of
men and reduces sperm motility
Dose: 20mg/day for 2-3 months followed by 40-
60mg/week
Intrauterine Contraceptive Device

(IUCD)
IUCD
Most commonly used method of long- acting
reversible contraception worldwide
High efficacy, safety, ease of use, low cost
Modern devices made of plastic and release either
copper or a progestin
Candidates for use
Intrauterine contraception is a good choice for women
who:
Desire one of the most effective methods of
contraception
Desire long-term yet reversible contraception
Want or need to avoid estrogen exposure (all IUDs) or
hormone exposure (copper IUDs)
Contraindications
Absolute:
Severe distortion of the uterine cavity
Active pelvic infection
Lifestyle risk factors for STI’s
Known or suspected pregnancy
Unexplained abnormal uterine bleeding
After hydatidiform mole
Current breast cancer
Copper allergy or Wilson’s disease (copper-containing
IUCDs)
Relative:
Specific hormonally sensitive conditions, such as
active liver disease (levonorgestrel- intrauterine
device)
Past ectopic pregnancy
Valvular heart disease
Insertion
Any time during the menstrual cycle
Copper IUCDs as emergency contraception if inserted
within 5 days of a single act of unprotected sexual
intercourse
Documentation of a negative pregnancy test
For women switching from a hormonal method of
contraception to an IUD, insert the IUD before
discontinuing the previous method
Method
A pelvic examination is done to assess the uterine size and position.
Antiseptic is used to clean the vagina and cervix at least twice.
A bivalve speculum is inserted.
The anterior lip of the cervix is steadied with a tenaculum.
A uterine sound or a graduated tube (included usually with the device)
is used to measure the distance from the fundus to the eternal os.
A sliding outer collar on the tube is pushed flush with the external os.
Depending on the device different techniques are used (push, pull,
withdrawal). Follow the manufacturer’s instructions carefully.
The threads are trimmed so that about 2-3 cm are visible past the
external os. The strings can be felt be the woman after each
menstruation to ensure the IUCD remains in situ and to allow
removal.
Steps that can reduce the risks of ascending infection
include
a. Clean the cervix thoroughly
b. Cut the string very short
c. Recommend an antibiotic (e.g. Augmentin) for 3 – 5
days
Possible mechanisms of action
Changes in cervical mucus that inhibit sperm transport
(eg, increased copper concentration, thickening,
glandular atrophy or decidualization)
Chronic inflammatory changes of the endometrium
and fallopian tubes, which have spermicidal effects
and inhibit fertilization and implantation
Thinning and glandular atrophy of the endometrium,
which inhibits implantation
Direct ovicidal effects
Types
Copper containing IUD
Progesterone releasing IUD
Copper containing
IUD
Paragard T 380A

 Mild foreign body reaction in endometrium toxic

to sperm and alters sperm motility
 Birth control (probability of pregnancy in the first
year is 0.6 percent)
 Emergency contraception (0.1% pregnancy rate)
 Up to 10 years
 After removal, fertility quickly returns
 Disadvantage: does not provide protection against
upper genital tract infections
 Side effects: Increased blood loss and duration of
menses, dysmenorrhea
Levonorgestrel
- intrauterine
device
Examples:
Mirena
52 mg LNg
initial release rate of 20 mcg/day
Average release at 5 years of about 10 mcg/day
5 years of use
Skyla
13.5mg LNg
Initial release rate of 14 mcg/day
3 years of use
Decidualization of the endometrium and thickening of the
cervical mucus
Minimal effect on ovulation
Probability of pregnancy in the first year is 0.1 percent
Side effects:
change in bleeding pattern, including prolonged bleeding (59
percent),
unscheduled bleeding (up to 52 percent)
amenorrhea (6 to 20 percent)
spotting (23 to 31 percent)
at the end of one year of use
Non-contraceptive benefits of 52 mg LNg IUDs include
reduction in:
menorrhagia and anaemia
dysmenorrhea
endometriosis-related pain
endometrial hyperplasia
PID
Complications
Vasovagal reaction
Presentation: presyncope, syncope, nausea, bradycardia, and hypotension
Management:
 Most resolve spontaneously
 Trendelenburg position, a cool pack or cloth on the head neck or chest, and an alcohol pad under the
nose

Perforation
Presentation:
 Severe or unrelenting pelvic pain
 Lack of anticipated normal fundal resistance of uterine sound or IUD applicator at time of insertion
 Active vaginal bleeding (ie, more than bloody discharge or spotting observed on speculum exam by
provider immediately after insertion)
 IUD string not visible or unusually short
Management:
 Unstable vital signs- emergency management including possible laparoscopic exploration
 Haemodynamically stable but IUD not deployed, vitals monitored and allowed home
 If IUD deployed, removal is indicated
Absent threads
From migration or perforation
Localisation- USS, X-ray
Expulsion
Highest in first 3 months and in nulliparous and less than 30 years
old
More likely if larger
Pregnancy and ectopic pregnancy
Pregnancy, if occurs, more likely to be ectopic
Pelvic infection
More likely in first 20 days
Removal if no response to treatment
Removal
When the patient desires to attempt pregnancy or after
the approved time stated on the package insert
Any time during the menstrual cycle
If fertility not desired, switch to alternative form of
contraception unless new IUD is being placed
immediately after removal of the old device or patient
switching to barrier method
Removal by grasping the strings with forceps and gently
pulling
Antibiotic prophylaxis, culture, or pathologic
examination is unnecessary for routine removals.
Thank You!
Any questions?
References
Bassaw, Bharat, MBBS, DGO, FRCOG, FACOG, MPhil, MMEd, and Fletcher Horace,
MBBS, FRCOG, FACOG, DM. The New Textbook of Gynaecology. St. Augustine. The
Multimedia Production Centre. Print
Carusi, Daniela A, MD, MPH, and Goldberg Alisa B, MD, MPH. “Intrauterine
contraceptive device: Insertion and removal.” UpToDate, 25 Oct. 2016,
www.uptodate.com/contents/intrauterine-contraceptive-device-insertion-and-removal?s
ource=see_link#H25

Dean Gillian, MD, MPH and Goldberg Alisa B, MD, MPH. “Intrauterine contraception:
Devices, candidates, and selection.” UpToDate, 12 Sept. 2017,
www.uptodate.com/contents/intrauterine-contraception-devices-candidates-and-selectio
n?source=search_result&search=intrauterine%20device&selectedTitle=1~150#H86812
48

Pocius , Katherine D, MD, MPH and Deborah A Bartz, MD, MPH. “Intrauterine
Contraception: Management of Side Effects and Complications.” UpToDate, 21 Aug.
2017,
www.uptodate.com/contents/intrauterine-contraception-management-of-side-effects-and
-complications?source=see_link#H497314865
Hagood Milton, Sarah. “Intrauterine Device Insertion.” Medscape, 18 Dec. 2015,
http://emedicine.medscape.com/article/1998022-overview#a4