FERTILITY AWARENESS METHOD & HORMONAL CONTRACEPTIVES

MIKAH S.

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OUTLINE

• INTRODUCTION
• FAM

Calendar

Temperature

Billings

Cervical palpation

Personal fertility monitor

• HORMONAL METHOD

Combined

Progesterone only

• CONCLUSION

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INTRODUCTION

A modern woman

• 420 menstrual cycle in her reproductive lifespan
• Earlier menarche
• Earlier coitache
• Less duration of breast feeding

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Speroff 2011

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Introduction

• End result

Difficulty limiting family size

Need for contraceptive imminent

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Over 50% of women world wide use contraceptives – low in Nigeria

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Methods evolved over 5 decades ago with degrees of improvement and modifications

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FAB Methods

• Involves avoidance of coitus at the fertile period of the menstrual cycle
• Cycle has to be regular
• Success depends heavily on compliance
• Methods differ in fertile period recognition

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Calendar ( Rhythm) method

• fertile period is calculated and intercourse is avoided during the period
• Depends on cycle length ( at least 6 cycles)
• Shortest cycle length minus 20 gives the beginning of the fertile period
• Longest cycle length minus 11 gives the end of the fertile period
• Failure rate 9%

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Billings or Mucus method

• Relies on the quality and quantity of cervical mucus
• Influenced by circulating oestrogen or progesterone
• Oestrogen- clear, thin and stretchy
• Progesterone- Opaque, sticky and less stretchy or disappears
• Failure rate 3%

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Temperature method

• A rise in body temperature of 0.2 to 0.5 degree centigrade due to progesterone
• This marks the end of the fertile period
• Affected by infection, medications and exercise
• Failure rate is 2%

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Cervical Palpation

• Self vaginal examination
• At mid cycle, the cervix rises by 1–2 cm
• feels softer and moist.

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Personal fertility monitor

• A portable monitor
• Analyses concentration of oestrogen and LH metabolites in the urine
• Identifies beginning and end of fertile period
• Shows red ( fertile phase) and green ( infertile phase) lines

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HORMONAL CONTRACEPTIVES

COMBINED HORMONAL

ORAL

TRANSDERMAL

VAGINAL

INJECTABLE

PROGESTOGENS ONLY

ORAL

IMPLANTS

INJECTABLE

IUS

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COMBINED ORAL CONTRACEPTIVES

• contain the oestrogen ethinyl oestradiol in a dose of 20 – 50 μg (low dose 20 – 35 μg)
• More recent pills contain oestradiol valerate

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Combined Oral Contraceptive

• The progestogens could be ;
• First generation eg norethisterone
• Second generation eg levonorgestrel
• Third generation eg gestodene,desogestrel and norgestimate
• There are newer progestogens with anti - androgenic activity such as drospirenone and dienogest.

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COC

• Over 200million users world wide
• Highly effective
• Failure rate 0.3%
• Most preparations are taken for 21 days

followed by a 7 - day break which may be replaced by a haematinic or placebo when withdrawal bleeding usually occurs

They can be monophasic, biphasic, triphasic or tetraphasic

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Non Contraceptive Benefits of COC

Improves Symptoms of;

• Heavy menstrual bleeding
• Acne and hirsutism
• Premenstrual syndrome
• Endometriosis
• Anaemia
• Dysmenorrhea
• Mid cycle pain

Reduces risk of ;

• Ovarian cancer
• Endometrial cancer
• Colorectal ca
• Benign breast masses
• PID

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TRANSDERMAL CONTRACEPTIVE

• 20 μg ethinylestradiol and 150norelgestromin daily.
• Each patch lasts 7 days
• Three patches are used consecutively with a placebo patch or patch - free interval in week 4 when withdrawal bleeding occurs
• Failure rate 0.3%

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Contraceptive Patch Ortho Evra�

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VAGINAL RING

• Releases 15 μg ethinylestradiol and 120 μg etonorgestrel daily
• Made of soft ethylene - vinyl – acetate copolymer,
• It has an outer diameter of 54 mm and a cross -sectional diameter of 4 mm.
• Designed to last for 3 weeks
• 7 - day ring - free interval is associated with bleeding

Failure rate is 0.3

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Vaginal Contraceptive Ring (NuvaRing).

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Combined Injectable Contraceptives

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Is given Monthly

• Some contain MPA combined with estradiol cypionate (E2C) eg Cyclofem, Lunelle (25mg MPA and 5 mg E2C)

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• Others contain Net-En combined with estradiol valerate (E2V) eg Mesigyna, Norigynon 50mg Net-En; 5mg E2V
• Failure rate 0.05%

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Mechanism of action of Hormonal contraceptives

• Inhibition of ovulation
• Change the characteristics of cervical mucus
• Alteration in tubal motility,
• Endometrial atrophy and impaired uterine receptivity

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Side effects combined Hormonal contraceptives

• Venous thromboemblism
• Myocardial infarction
• Stroke
• Breast Ca
• Hepatic adenoma
• Chollelithiasis
• Nausea and vomiting
• Leg cramps
• Facial pigmentation

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Side Effects – Cont’d

• Affects hepatic metabolism
• Weight gain
• Headache
• Loss of libido
• Mastalgia
• Breast engorgement
• Fluid retention

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Absolute contraindication Combined hormonal contraceptives

• Ischaemic heart disease
• Severe liver disease
• Suspected genital tract or breast ca
• Hypertension or vascular disease
• Thrombo-embolism
• Migraine with aura
• pregnancy

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Relative Contraindication

• Irregular pv bleeding
• Obesity
• DM
• Prolonged immobilization
• SCDx

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PROGESTERONE-ONLY CONTRACEPTIVES

• They avoid oestrogen side effects
• Available in oral, injectables, implants and IUDs

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Oral Progestogens

• Older ones contain second generation
• New preparations contain 3^rd generation – desogestrel
• Failure rate is 0.5%

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Injectable progestogens

Depot medroxyprogesterone acetate (DMPA)

Microcrystalline

• Deep intramuscular injection, 150 mg
• 3 monthly

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Norethisterone Enanthate (Net-En) 200 mg

• In oil
• 2 monthly
• Failure rate is 0.3%

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Injectables

• More women are using injectable because of:
• Effectiveness
• Long acting
• Convenience

Privacy guaranteed

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Subdermal Implants

• Initially Six Rods- Norplant (now discarded)
• Two rod Jadelle (levonorgestrel) – 5 years
• One rod Implanon (etonogestrel) – 3 years
• Bio-degradable that does not require removal Capronor (2 years) Developed by Research Triangle Institute
• Failure rate is 0.05%

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Norplant Implants

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Jadelle Implants

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Jadelle Implants (2 capsules)

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Implanon Implant

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Intrauterine System

Mirena ( UK and Canada)

• T - shaped plastic frame with a reservoir on the vertical stem
• Containing 52 mg levonorgestrel releasing 20 μg/day
• Last for 5 years.
• Failure rate is 0.1%

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Intrauterine System

• Levo-Nova (registered in Finland)

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• Other Uses:
• Treatment of Menorrhagia
• In HRT

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Intrauterine System

Progestasert

• developed in 1976
• manufactured in 2001.
• It contains progesterone released at a rate of 65 micrograms per day.
• Replaced annually, though approved for 18 months of use in France.
• It had a failure rate of 2% per year

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Mechanism of action of progesterone only contraceptives

• Inhibition of ovulation
• Effect on cervical mucus
• Endometrial atrophy

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Side effects

• Unpredictable bleeding patterns
• Amenorrhea
• Heavy prolonged bleeding
• Delay in return to fertility
• Functional ovarian cysts or persistent follicular cysts
• Reduction in bone mineral density
• Mood swings
• Reduced libido

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The Future of Injectable Contraceptives

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• Addition of small quantities of testosterone to injectable to:
• Correct risk of osteoporosis from long term use!
• Correct risk of reduced libido

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Contraindications

• Stroke
• Breast cancer, past and with no evidence of disease for 5 years
• Liver tumours, Cirrhosis
• Current or history of ischaemic heart disease or stroke
• Unexplained vaginal bleeding (injections, implants and IUS)
• Use of certain drugs: some antiretrovirals, some anticonvulsants (progestogen - only pills and implants)
• Multiple risk factors for arterial cardiovascular disease (injectable only)
• Vascular disease (injectable only)
• Antiphospholipid antibody
• Severe thrombocytopenia (injectable and implant only)
• Diabetes with nephropathy, neuropathy, retinopathy, other vascular disease (injectable only)
• Distorted uterine cavity (IUS only)

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THANK YOU

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