• Family planning is the way for a couple to have healthy children at the desired period and in number and to prevent unwanted pregnancies. If 85% of women in the fertile age group are not protected, they will become pregnant within 1 year.
contraceptive methods
1. Natural methods
• Sexual abstinence
- Basal body temperature method
- Calendar method
- Cervical mucus method
- Symptothermal method
• Vaginal douche
• Coitus interruptus
• Breast-feeding
2. Barrier methods
• Condom
• spermicide
• Diaphragm
• cervical cap
• Sponge
3. Intrauterine devices (IUD)
• Copper IUDs
• Levonorgestrel-releasing IUDs
4. Hormone (contraceptions)
• Combined oral contraceptives (COCs)
• Mini (pure progesterone) pills
• Injectable contraceptives
• Subcutaneous implants
• Transdermal patches
• Transvaginal rings
5. Postcoital contraception
6. Surgical sterilization
• Tubal ligation
• Vasectomy
Natural contraceptive methods
Sexual Abstinence
• Avoiding intercourse during the ovulatory period when the risk of pregnancy increases. There are several methods for estimating ovulation. The main reason for the failure of the method is that the sperm can stay alive in the female genital tract for 5-7 days.
► Basal body temperature method
► Calendar method (Opino-Kraus method); least effective natural method
► Cervical mucus method (Billings method)
► Symptothermal method (calendar + mucus method)
Coitus interruptus
• It is the withdrawal of the penis from the vagina before ejaculation. However, since pregnancies can occur as a result of ejaculate to the external genitalia without penetration of the penis, it should be completely withdrawn from both the vagina and the external genitalia. It has as much effectiveness as a condom.
• It reduces the risk of HIV infection in monogamous couples.
Breast-feeding
• Increasing prolactin decreases GnRH pulsatility in lactating women. Due to the decreased GnRH pulsatility, LH decreases and ovulation is prevented. This suppression period varies depending on the frequency and duration of breastfeeding.
• In mothers who do not breastfeed after birth, ovulation starts after 6 weeks at the earliest. As a result of full breastfeeding at maximum 4 hours during the day and 6 hours at night and not giving additional food, ovulation is generally prevented for 6 months (98%), but it is necessary to start contraception earlier to prevent earlier ovulation and unwanted pregnancies. For this purpose, the rule of 3 is applied:
- In non-breastfeeding or partially breastfeeding mothers, at the latest in the third postpartum week,
- In fully breastfeeding mothers, a contraceptive method should be started at the latest in the postpartum 3rd month.
- The use of combined estrogen and progesterone hormonal contraceptives (COC, transdermal patches and vaginal ring) is not recommended during breastfeeding, as estrogens suppress galactogenesis.
• Hormonal contraceptives containing progesterone alone (minipill, implant, injectable, LNG-IUD) do not affect the amount of milk. Barrier methods, spermicides, and copper IUDs are the best options for breastfeeding women
BARRIER METHODS
The most important advantages of barrier methods are that, in addition to providing contraception, they also provide protection from sexually contagious diseases and related cervical dysplasia, cervical malignancies and tubal infertility.
condom
• They can be latex or nan-latex. Since it is not impermeable to Chlamydia, gonococci, Ureaplasma, HSV, HPV, HIV infection and Hepatitis B-C, it provides protection against sexually contagious diseases and PID, and consequently reduces the incidence of CIN and cervical cancer.
• It is commercially available in the form of male condom and female condom (femidom). Femidoms do not alter the vaginal flora and do not cause mucosal trauma.
Diaphragm
• It is a latex barrier that is placed between the posterior fornix and the anterior vaginal wall and closes the cervix. The vaginal diaphragm should be left in place for at least 6 hours after coitus. The use of spermicide with the diaphragm should always be recommended.
• It increases the risk of urinary infection (cystitis) when used frequently.
Diaphragm should not be preferred in patients with a history of toxic shock, as it may be associated with toxic shock syndrome.
cervical cap
• It is smaller than the diaphragm, sits right on the cervix and can remain for 72 hours. It is used together with spermicides and its effectiveness is lower than that of the diaphragm.
• Contraceptive efficacy varies by parity and is more effective in nulliparous women.
spermicide
• Contains various chemicals used for immobilization and fragmentation of spermatozoa. The most commonly used agents today are nonoxynol-9 and octoxynol. These agents, which are available in aerosol foam (the most effective), cream, foam, suppository, gel and vaginal ring forms, should be applied to the vagina 30 minutes before intercourse.
• Spermicides are not absorbed from the vagina and do not increase the risk of congenital anomaly.
Less effective than condom and diaphragm alone.
• Nonoxynol-9 often causes genital lesions and in these lesions increases the risk of STD and HIV infection of the user. Nonoxynol-9 is also toxic to lactobacilli, and in women using it, the colonization of E.coli in the vagina may increase, leading to postcoital E.coli bacteriuria.
The use of spermicide is strictly contraindicated in those with high risk of HIV infection and those with HIV infection.
Sponge
• They are dome-shaped polyurethane vehicles containing nonoxynol-9. Contraceptive efficacy varies by parity and is more effective in nulliparous women.
Intrauterine devices (IUD)
Main Effect Mechanisms
1. From endometrial cells; forming a biological foam by the release of fibrin, phagocytic cells and proteolytic enzymes
2. To cause contraction by increasing the release of prostaglandins in the uterus
3. Causing sterile inflammation in the endometrial cavity that will prevent spermicidal and implantation
IUDs do not have an abortion effect.
Types of Intrauterine Device
Copper IUD
► There is copper in the arms and body of these IUDs. Contraceptive effectiveness continues for up to 10 years.
► In addition to the classical IUD effects in its mechanism of action, it reduces sperm motility with released copper ions and prevents the acrosomal reaction of sperm.
► It has been shown that spermatozoa in the endometrial cavity undergo phagocytosis 2-16 hours after coitus in women using copper IUDs.
Levonorgestrel Release IUD (LNG-IUD)
► There are forms containing 52 mg, 19.5 mg and 13.5 mg LNG. The contraceptive effectiveness of forms containing 52 mg of LNG continues for up to 5 years.
► In addition to the classical IUD effects, the main mechanism of action is that the cervical mucus becomes thick/viscous and loses its permeability to spermatozoa. It also suppresses the endometrium. It may cause anovulation by causing suppression of gonadotropins in 15% of cycles.
► Benefits of LNG-IUDs other than contraception:
0 Protects against endometrial cancer
0 Reduces symptoms of endometriosis and adenomyosis
0 Reduces dysmenorrhea and menorrhagia
0 Reduces menorrhagia due to fibroids
0 Decreases incidence of ectopic pregnancy
0 Protects against pelvic inflammatory diseases
LNG-IUD is one of the methods that can be preferred in patients with dysmenorrhea, menorrhagia and anemia who cannot use estrogen-containing contraceptive methods (such as smoking).
Clinical Applications of Intrauterine Devices
IUD Application Time
► An IUD can always be inserted in a woman who is sure that she is not pregnant and antibiotic prophylaxis is not required.
► IUD can be inserted immediately after vaginal delivery, cesarean section, or first or second trimester miscarriage. However, the ideal time for IUD insertion is 6-8 weeks after delivery and second trimester miscarriage, so that the IUD is not expelled and unwanted pregnancies do not occur.
► Since IUDs can be inserted more easily (due to cervical dilation) and it is an indication that the patient is not pregnant, the most appropriate time is during or just after menstruation.
IUD and CVS Diseases
► Contraception is a special problem in patients with heart valve disease. Since pregnancy and COC are risky in these cases, IUDs are considered appropriate.
► IUD can be inserted in patients with subacute bacterial endocarditis and mitral valve prolapse (Barlow syndrome). Prophylaxis with 2 g of amoxicillin should be done 1 hour before the procedure.
► Again, IUD is one of the most ideal contraceptive methods, especially in diabetic patients with vascular involvement.
IUD and Pelvic Inflammatory Diseases
► The use of copper IUD does not increase the risk of pelvic inflammatory diseases in the long term, especially in monogamous couples. The IUD should not be inserted if the patient has an active chlamydia or gonorrhea infection or has purulent cervicitis. The risk of pelvic inflammatory disease increases in the first 20 days after insertion. Subsequently, the risk of developing pelvic inflammatory disease is similar to that of the general population.
► If PID is suspected in a woman using an IUD, a culture is taken and broad-spectrum antibiotics are started. However, if the picture does not improve within 72 hours, the IUD is removed. In case of detection of tubovarian abscess, the IUD should be removed immediately after starting antibiotic use.
► It is known that there is an increase in the colonization of Actinomyces in the cervix in women with IUD, and actinomycosis is the only pelvic infection completely related to IUD. This increase in risk is less in copper IUD than in LNG-IUD. Symptomatic patients should be treated with antibiotics and the IUD should be removed. In asymptomatic patients, the IUD should not be removed.
IUD and Bleeding
► Menstrual bleeding may increase by 30%, especially in those using copper IUDs. The first approach in these patients should be to use prostaglandin synthesis inhibitors (mefenamic acid etc.) or tranexamic acid. If there is no response to this treatment, then the copper IUD can be removed and replaced with an LNG-IUD.
► Sometimes progesterone rupture bleeding may occur in cases with LNG-IUD. In this case, patients are followed up and oral low-dose estrogen can be added if necessary.
IUD and Pregnancy
► If continuation of pregnancy is desired, the IUD should be withdrawn as early as possible (usually until the 14th week of pregnancy).
► The overall miscarriage rate in patients after IUD removal is 30%; however, the IUD, whose thread is seen and easily removed in the early period, does not increase the risk of spontaneous abortion. The IUD, whose thread cannot be seen or pulled (fundal localized), is left in place.
► IUD during pregnancy does not cause congenital malformation, increase in IUGR and perinatal mortality; however, it may cause septic abortion, chorioamnionitis, premature rupture of membranes, premature birth, abruption, placenta previa, cesarean delivery and low birth weight in the following weeks of pregnancy.
IUD and Ectopic Pregnancy
► Since all contraceptive methods are protective against pregnancy, they are also protective against ectopic pregnancy.
► However, the risk of ectopic pregnancy increases in the failure of the contraceptive method. If pregnancy occurs during IUD use, the risk of ectopic pregnancy is increased.
IUD and Fertility
► The risk of infertility due to tubal factor does not increase in nulliparous women with copper IUD.
Lost IUD
► In this case, first of all, a pregnancy test is performed to rule out a possible pregnancy. If the test is negative, it is checked whether the IUD is in the cavity with USG. If the IUD has slipped towards the cervix, it should be removed as contraceptive adequacy will decrease. If the threads are not visible, they are removed from the cavity with Novak curette or hysteroscopy.
► If the IUD is not in the cavity, abdominal films (x-ray) should be taken to check whether it has advanced to the abdomen or pelvis. should be removed by laparoscopy or laparotomy. May cause visceral injuries if left in place.
Contraindications of IUD
Copper IUD Contraindications
► Pregnancy or suspected pregnancy
► Undiagnosed abnormal genital bleeding
► Conditions disrupting the uterine cavity
0 Congenital anomalies (bicornu, septa, etc.)
0 Submucous fibroids
► Genital infections
0 Acute pelvic inflammatory disease
0 Postpartum/postabortal endometritis and puerperal sepsis in the last 3 months
0 Mucopurulent cervicitis
► Conditions with a high risk of pelvic infection (multiple partners, leukemia, AIDS and IV substance abuse)
► Known or suspected endometrial or cervical cancer
► Presence of previously inserted and not removed IUD
► Patients under hCG follow-up due to gestational trophoblastic disease
► Copper allergy
► Wilson's disease
LNG-IUD Contraindications
► Pregnancy or suspected pregnancy
► Undiagnosed abnormal genital bleeding
► Conditions disrupting the uterine cavity
0 Congenital anomalies (bicornu, septa, etc.)
0 Submucous fibroids
► Genital infections
0 Acute pelvic inflammatory disease
0 Postpartum/postabortal endometritis and puerperal sepsis in the last 3 months
0 Untreated acute cervicitis, vaginitis or other lower genital tract infections
► Conditions with a high risk of pelvic infection (multiple partners, leukemia, AIDS and IV substance abuse)
► Known or suspected endometrial or cervical cancer
► Presence of previously inserted and not removed IUD
► Patients under hCG follow-up due to gestational trophoblastic disease
► LNG hypersensitivity
► Known or suspected breast cancer
► Acute liver disease and liver tumor (benign or malignant}
► To use for postcoital contraception
HIV infection, diabetes with vascular complications, mitral valve prolapse, subacute bacterial endocarditis and SLE are not absolute contraindications for IUD use. IUDs can also be used in nulliparous women and adolescents. Postpartum and postabortal insertion is also safe (but the risk of expulsion is high).
Complications and Side Effects
1. Uterine perforation (at the time of insertion)
2. Ectopic pregnancy (if pregnancy occurs)
3. Dysmenorrhea (in copper IUDs)
4. Menorrhagia (in copper IUDs)
5. Iron deficiency anemia (with long-term use of copper IUDs)
6. Metal allergy (in copper IUDs)
7. Oligomenorrhea / Amenorrhea (in LNG-IUDs)
8. Functional ovarian cysts (in LNG-IUDs)
Hormonal methods of contraception
• These are the methods applied by giving synthetic estrogen and progesterone or only progesterone.
• It can be given orally, patch, implant, injectable or vaginal ring.
Combined Oral Contraceptives (COCs)
• It is the most commonly used hormonal method and it is available in monophasic (tablets containing the same amount of steroids) or multiphasic (tablets containing steroids in different doses) for 21, 24 or 28 days.
• The most important problem with the sex steroids contained in POPs is that they are immediately inactivated when taken orally. Oral bioavailability is increased by adding the ethinyl group to the C17 atom of estradiol in the estrogen content (ethinyl estradiol).
• Another estrogen derivative used in POPs is mestranol, the 3 methyl ester of ethinyl estradiol. 35 µg of ethinyl estradiol is equal to 50 µg of mestranol. They are effective for 24-36 hours following oral ingestion.
• Today, COCs have come into use as the hormonal contraceptive method with the lowest estrogen content (10 µg).
The most commonly used estrogens in COCs are; ethinyl estradiol and mestranol. Other estrogens used in COCs are estradiol cypionate and estradiol valerate.
• In new progestins (desogestrel, gestodene, norgestimate), glucose and insulin balance is less affected, SHBG increase and free testosterone decrease are more pronounced, and the lipoprotein profile is less affected.
• Drospirenone is the newest synthetic progestin (4th generation). It is a spironolactone analog with aldosterone antagonist effects. It is agonistic for progesterone and antagonistic to mineralocorticoids and androgens. Difference from other synthetic progestins; It does not cause water and salt retention due to the lack of mineralocorticoid effect, no glucocorticoid effect and direct antiandrogenic effect.
Because of these effects, drospirenone is preferred especially in premenstrual syndrome and hyperandrogenemia (acne, hirsutism).
17-a acetoxyprogesterone derivatives (medroxyprogesterone acetate = MPA} are not used in the structure of COCs as they can inhibit ovulation at high doses
Effect Mechanisms
► Ovulation inhibition: They inhibit the release of gonadotropin (LH and FSH) from the pituitary. While estrogen alone can suppress follicular development by suppressing FSH, progestins can inhibit ovulation by suppressing LH. Inhibition of ovulation is a dose-dependent effect.
► Progestins prevent sperm migration by thickening the cervical mucus.
► Progestins affect tube motility, impair sperm and ovum transport, prevent pregnancy by inhibiting sperm capacitation.
► Progestins make the endometrium unsuitable for blastocyst placement. Estrogens also stabilize the endometrium and increase the effect of progestin by increasing progestin receptors.
COCs are cumulatively PROGESTAGENIC on genital tract
Non-Contraception Benefits of COCs
clearly demonstrated benefits
- Reduces ovarian and endometrial cancer
- Reduces colorectal cancer
- Makes cycles regular
- Reduces dysmenorrhea and Mittelschmerz
- Reduces menstrual bleeding and iron deficiency anemia
- Reduces benign breast diseases (fibroadenoma, fibrocystic diseases)
- Reduces functional ovarian cysts (dose dependent effect)
- Reduces pelvic inflammatory diseases Reduces ectopic pregnancy
- Treats menorrhagia and dysfunctional uterine bleeding
Possible benefits
- Increases bone density
- Prevents atherosclerosis
- Reduces acne and hirsutism
- Reduces rheumatoid arthritis
- Treats endometriosis
- Reduces premenstrual symptoms
- Treats hyperandrogenemic anovulation
- Treats perimenopausal changes
- Reduces the incidence of fibroids
Complications of COCs
Complications of Thromboembolism
Estrogen in 0 COC increases the production of coagulation factors and suppresses the fibrinolytic system. Probably due to its effects on the liver, especially factor VII levels increase, while antithrombin III levels decrease within 10 days. Progestins have no significant effect on coagulation factors.
Partial thromboplastin and prothrombin times are shortened in many women using COCs.
While the use of hormonal contraceptive methods that use estrogen increases the risk of venous thromboembolism, there is no relationship with venous thrombosis in progesterone-only oral contraceptives and levonorgestrel-containing IUD.
COC users have an increased risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism). This increase in risk is dose-dependent and is valid for the duration of use. During COC use, the risk of thrombosis is highest in the first year, and then the risk decreases somewhat. The risk of venous thromboembolism (VTE) drops dramatically following discontinuation of the COC.
The risk of thromboembolism is reduced by reducing the dose of estrogen in COCs.
A detailed investigation should be performed in a woman who has had a venous thromboembolism during COC use. Genetic thrombophilias and AFAS should be investigated. Factor V Leiden mutation and protein C and S deficiency are observed in most of the cases with VTE. Therefore, screening for factor V Leiden mutation before COC is appropriate in patients with a previous episode of VTE or in women with a family history.
Estrogen-containing COCs, transdermal patches, or vaginal rings should not be used in women with a Factor V Leiden mutation.
COC users also have an increased risk of arterial thromboembolism (myocardial infarction and stroke). However, these risks are especially increased in those who use high-dose estrogen-containing COCs, those in the advanced age group (>35 years old), hypertensive and smokers.
There is no increase in the risk of stroke and myocardial infarction in non-smoking patients using low-dose estrogen combined oral contraceptives.
COC can be given to women over 35 years of age if they do not have cardiovascular disease risk factors and do not smoke.
Hypertension
0 COCs can cause a rise in blood pressure. The mechanism responsible for this effect is thought to be that estrogen increases the production of angiotensinogen in the liver and, accordingly, an increase in the renin substrate. This effect is dose dependent.
0 5% of COC users may develop hypertension after 5 years of use. Blood pressure usually returns to normal following discontinuation of the drug. COC can be used in well-controlled hypertensive patients, low-dose preparations should be given.
Liver
0 Estrogens increase hepatic DNA and RNA synthesis and binding globulins (primarily SHBG).
0 While the active transport of bile is impaired in women using high-dose COCs, this effect is not observed in low-dose users. COCs may cause the development of gallbladder diseases in susceptible individuals, but there is generally no increased long-term risk. However, acute or chronic cholestatic diseases of the liver are an absolute contraindication for COCs.
0 Depending on the duration of COC use, benign liver adenomas and focal nodular hyperplasia may develop. The clinical significance of these tumors is that they have the potential for serious bleeding. The picture may regress following discontinuation of the drug. The risk is associated with prolonged use of high-dose COCs, with low-dose new COCs having a lower risk.
lipid panel
0 COCs generally increase triglycerides and total cholesterol. Estrogens in its content reduce the risk of atherosclerosis by increasing HDL and decreasing LDL; On the other hand, progestins (especially those with androgenic potency) decrease HDL and increase LDL and partially antagonize this positive effect. Oral estrogens also increase triglycerides. Low-dose COCs have minimal side effects on the lipid profile.
carbohydrate metabolism
0 High-dose COCs cause glucose intolerance and this effect is dependent on peripheral insulin resistance. Plasma glucose and insulin levels increase in these women. It can cause an abnormal glucose tolerance test. These effects are due to the progestins in typical POPs content. Estrogen alone does not have a negative effect on glucose metabolism; When taken together with progesterone, it creates insulin antagonism.
0 COCs can be used in patients with well-controlled diabetes. It has no effect on retinopathy and nephropathy.
endocrine effects
0 Estrogens increase cortisol binding globulin (transcortin) and cortisol levels.
0 Estrogens increase the synthesis and circulating levels of thyroid binding globulin. Plasma total thyroxine (T4) levels increase, but free T4 level remains normal. T3 resin uptake is reduced.
Metabolic effects
0 Nausea, breast tenderness and weight gain are less common in low dose preparations.
0 Estrogens in COCs can cause chloasma. This is hyperpigmentation that occurs in the form of a mask on the skin. It is usually transient and less observed at low doses.
0 Sedimentation rate increases during COC use.
0 In addition, while the level of vitamin A increases, pyridoxine (Vit B6) and vitamin C decrease.
0 It may rarely cause the development of depression and it develops due to the progestins in the COC content. In these cases, discontinuation of the drug is recommended.
0 No change in creatinine and globulin levels
0 Total bilirubin and alkaline phosphatase are decreased.
cancers
1. They reduce epithelial ovarian cancer (50% in 3 years, 80% in 10 years)
2. They reduce endometrial cancer (40% in 2 years, 60% in 4 years)
3. They reduce colorectal cancers (20-40%)
4. They increase cervical cancer (villoglandular papillary) (2 times in 12 years)
5. They increase hepatocellular adenoma.
6. They increase the risk of partial mole hydatiform.
7. They increase breast cancer.
8. They do not increase hepatocellular cancer
Regarding the relationship between breast cancer and COCs, some reference books state that the use of COCs increases the risk of breast cancer, while another reference book states that there is no relationship between COCs and breast cancer.
Effects on reproductive health
0 There is no increased risk to pregnancy and fetus in women who have used COCs before. COCs did not increase the risk of spontaneous abortion, and the risk of miscarriage was decreased in those with a history of COC use.
0 An increase in the rate of dizygotic twins may be seen in the first cycles following discontinuation of the drug in women using COCs.
0 Fertility returns in a short time when COCs are stopped.
There is no relationship between the use of hormonal contraceptives and teratogenicity.
infections
0 COCs have no effect on viral infections (HIV infection, HSV, HPV, etc.).
0 COCs cause the development of vaginitis and its frequent recurrence by shifting the vaginal pH to alkaline.
0 Again, they cause ectropion and increase the colonization of chlamydia in the emerging columnar epithelium, but at the same time, they prevent the spread of these infections to the upper genital tract and protect them from pelvic inflammatory disease as they form a cervical mucus plug.
Bleeding irregularities
The cause of breakthrough bleeding when using COCs is progesterone breakage bleeding. The lower the level of ethinyl estradiol in the COC, the higher the risk of breakthrough bleeding. In case of refractory bleeding during low-dose COC use, a preparation with higher estrogen content or a different progesterone may be used (for example, levonorgestrel).
0 There may be a case of not having a period for 6 months after stopping the COC. It is more common in women with previous menstrual irregularities. The incidence of pituitary adenoma is also high in these cases.
Migraine headache
0 Menstrual migraine-type pain may benefit from continuous COC use. The occurrence of true vascular migraine headaches (with aura) requires immediate discontinuation of COCs. The presence of neurological symptoms or aura is associated with the risk of stroke. In these cases, only progestin-containing pills should be used.
drug interactions
COC drug interactions
Drugs that decrease POP activity by increasing liver enzyme activity (An alternative contraceptive may be needed when these drugs are used)
• Rifampin• Topiramate
• Griseofulvin
• Nevirapine
• Phenytoin, mephenytoin
• Ketoconazole, itraconazole
• Phenobarbital
• Ciprofloxacin, ofloxacin
• Pyrimidon
• Ampicillin, penicillins
• Carbamazepine, oxcarbazepine
• Tetracycline, doxycycline
• Felbamate
• Antiretrovirals
• Ethosuximide
COCs change the plasma levels of some drugs and substances
• Diazepam, alprazolam (level increases)• Tricyclic antidepressants (level increases)
• Aminophylline, theophylline (level increases)
• Cyclosporine (level increases)
• Ethanol (level increases)
• Caffeine (level increases)
• Meperidine (level increases)
• Imipramine (level increases)
• Corticosteroids (level increases)
• Metaprolol (level increases)
• Cyclofenthiazide (decreased level)
• Acetaminophen, Salicylic acid (decreased level)
• Morphine (decreased in level)
• Lamotrigine (decreased level)
• Temazepam (decreased level)
COC use also negatively affects the quality and quantity of lactation.
Symptoms and approach during combined oral contraceptive use
Conditions in which oral contraceptives should be discontinued immediately
- Diplopia, vision loss ---------------------► Possible retinal artery thrombosis
- Unilateral numbness, weakness---------► Possible cerebrovascular accident
- Severe chest, neck pain ------------------► Possible myocardial infarction
- Speech disorder ---------------------------► Possible cerebrovascular accident
- Leg pain and tenderness -----------------► Possible thrombophlebitis
- Hemoptysis, dyspnea ---------------------► Possible pulmonary thromboembolism
Special cases in the use of COCs
1. If there are complaints of weight gain, water retention, acne and hirsutism, an agent with drospirenone should be preferred.
2. The risk of malformation does not increase in pregnancies that occur during COC use.
3. If amenorrhea persists for more than 6 months after discontinuation of the COC, prolactinoma should be investigated.
4. COC should be discontinued 4 weeks before elective surgery.
5. They may increase the frequency of attacks in patients with SLE.
6. COC does not increase adenoma size in patients with pituitary microadenoma.
7. May increase sickling in patients with sickle cell anemia.
8. Pregnancy risk in obese women using COCs is similar to or slightly increased in non-obese women
Strict Contraindications of COCs
► Known or suspected pregnancy
► Undiagnosed abnormal genital bleeding
► Acute or previous thrombophlebitis or thromboembolic diseases
0 Acute or previous deep vein thrombosis/pulmonary embolism
0 AFAS and thrombophilias
0 Acute or previous cerebrovascular diseases (including migraine with aura)
0 Acute or previous coronary artery diseases
0 Thrombogenic heart valve diseases
0 Thrombogenic cardiac arrhythmias
► Severe and labile hypertension {systolic 160 mmHg, diastolic 100 mmHg)
► Diabetes with vascular involvement
► Smoking aged 35 and over
► Cancers
0 Known or suspected breast cancer
0 Known or suspected endometrial cancer
0 Other known or suspected estrogen-dependent neoplasms
0 Hepatocellular adenoma, adenocarcinoma or malignant hepatoma
► Acute liver diseases (or other liver diseases that cause liver failure)
► Major operation or severe trauma that may cause prolonged immobilization
► History of cholestatic jaundice during pregnancy or jaundice due to drug use
Pills Containing Progesterone Only (Minipill)
• They contain only progesterone (0.3 mg norethindrone). Since they are very low dose, their contraceptive efficacy is also low.
• However, they provide more effective contraception in lactating women and women over 40 years of age.
• They can also be used safely in patients with hypertension, migraine, SLE, sickle cell anemia, atrial fibrillation, mitral valve prolapse and coagulopathy. It is started on the first day of menstruation and is used without interruption during the entire cycle. Pills should be taken at the same time of day.
Main mechanisms of action
1. Ovulation trigger cannot be pulled because LH is suppressed: This effect is dose dependent of progesterone.
2. They thicken cervical mucus
3. They disrupt tubal motility
4. They prevent implantation by thinning the endometrium
Advantages
► Its effects on carbohydrate metabolism and coagulation are minimal.
► It does not cause severe hypertension.
► It can be used in patients at risk of cardiovascular complications (history of thrombosis, hypertension, migraine headaches, smokers over 35 years of age).
► There is a quick return to fertility.
► It is the ideal choice for those who are breastfeeding (it can be started on the 3rd postpartum day).
► Does not increase the risk of venous thromboembolism.
Side Effects and Complications
► Irregular bleeding (progesterone breakage) is common and is the most important reason for discontinuation of the method.
► Amenorrhea may develop in long-term use.
► Increases the risk of ectopic pregnancy (if pregnancy occurs).
► Increases functional cyst formation in the ovary.
► SHBG decreases in mini-pill users and acne may occur.
Strict Contraindications
► Known or suspected pregnancy
► Existing breast cancer
Injectable Contraceptives (Depot Medroxyprogesterone Acetate= MPA)
• A single 150 mg dose of MPA suppresses ovulation for 14 weeks or longer. Therefore, every 3 months it is applied intramuscularly, MPA is used only in this form among all contraceptives
• Its efficacy is equivalent to sterilization in women and it is very high dose, Their effectiveness is not reduced by the use of drugs that induce enzyme in the liver.
• Their effectiveness is also not related to body weight, and their effectiveness is not reduced in obese women. It may take up to 18 months for fertility to return.
Main Effect Mechanisms
1. They suppress LH with the progesterone they contain and ovulation does not occur.
2. They thicken cervical mucus.
3. They prevent implantation by thinning the endometrium.
4. They disrupt tubal motility.
• FSH suppression achieved by depot MPA injection is not as pronounced as with COCs. Therefore, there is follicular development, but the estrogen produced is as much as in the early follicular phase of the normal cycle. Urogenital system and breast atrophy due to decreased estrogen does not occur, but bone density decreases {osteopenia). This effect is reversible when the drug is discontinued. In case of use in adolescents, a diet rich in calcium is recommended.
Indications
► Demand for effective and long-term contraception
► Situations where COC use is contraindicated
► Breastfeeding
► Sickle cell anemia
► Epilepsy
Non-Contraception Advantages
Non-contraception advantages
1. It reduces endometrial cancer.
2. It significantly reduces iron deficiency anemia.
3. It reduces the incidence of ectopic pregnancy.
4. It reduces the risk of pelvic infection.
5. It reduces the occurrence of dysmenorrhea.
6. Prevents premenstrual syndrome.
7. It reduces convulsion attacks in epilepsy (they increase the convulsion threshold).
8. It effectively treats endometriosis.
9. It reduces sickling in sickle cell anemia.
10. Increases the amount of milk in lactation; postpartum can be started after the 6th week,
11. It reduces the incidence of uterine fibroids.
12. reduces the risk of vertebral cancer.
13. Decreases functional ovarian cysts.
Strict Contraindications
► Known or suspected pregnancy
► Known or suspected breast cancer
Side Effects and Complications
► Irregular bleedings (progesterone breakthrough bleeding); It is one of the most common reasons for discontinuation of the method.
► Oligomenorrhea, amenorrhea
► Headache; It is one of the most common reasons for discontinuation of the method.
► Weight gain, fluid retention, breast swelling
► Anxiety, depression, decreased libido
► Liver dysfunction
► Bone mineral density loss
► Slight decrease in antithrombin III level
► impaired glucose tolerance; cause glucose elevation in the challenge test.
► Total cholesterol, triglyceride and HDL decrease. LDL is unchanged or slightly decreased.
► They slightly increase the risk of breast cancer.
► increase the risk of cervical cancer in situ.
The use of depot MPA does not increase the risk of teratogenicity, thrombotic complications and MI.
The most common reason for discontinuation of MPA use is headache in some of the reference books; In other reference books, it is stated that there is irregular bleeding. Low-dose estrogen, mifepristone, and doxycycline can be used in the treatment of bleeding during depot MPA use.
Injectable methods that include estrogen (estradiol cpionate) together with progesterone (25 mg depot MPA) are also available and are used monthly.
Subcutaneous Implants
• While the effectiveness of Norplant containing 216 mg of levonorgestrel is 7 years; The effectiveness of Implanon, which contains 68 mg of etonorgestrel, is 3 years. Implants are placed in the biceps space on the inner surface of the upper arm.
• Fertility returns quickly after the methods are discontinued. 50% of the cases ovulate 3 months after the implant is removed. Immediate postpartum insertion does not cause adverse effects for mother and infant.
Main mechanisms of action
1. They suppress LH with the progesterone they contain and ovulation does not occur
2. They thicken cervical mucus
3. They prevent implantation by thinning the endometrium
4. They disrupt tubal motility
Indications
► Demand for effective and long-term contraception
► Situations where COC use is contraindicated
► Anemia due to excessive menstruation
► 1-2 years of desire to breastfeed
► Having a chronic disease
Absolute contraindications
► Known or suspected pregnancy
► Existing breast cancer
Side Effects and Complications
► Progesterone breakout bleeding
► Oligomenorrhea, amenorrhea
► Headache
► Acne, hirsutism
► Emotional lability
► Weight gain
► Mastalgia
► Ovarian cysts
• Irregular bleeding is the main reason for leaving. While it is common in the first 90 days, it decreases afterward.
• Since ovarian follicular activity is not fully suppressed and estrogen synthesis continues, it has no effect on bone density. It does not have significant effects on the coagulation and fibrinolytic system and does not increase the risk of thrombosis. Lipid profile and liver function tests do not change
• The risk of pregnancy increases with the use of levonorgestrel implants over 70 kg. however, this risk is still low. No pregnancy was observed in the first 3 years in women of any weight.
Transdermal Patches
• Patches that release 20 µg ethinyl estradiol and 150 µg norelgestromin (active metabolite norgestimate). When applied to the arm, hip or lower abdomen, it should not be applied to the breasts. It remains in place for 3 weeks after the application and 1 week is waited for the final withdrawal bleeding.
• Failure rates are slightly lower for women using low-dose COCs, however; dysmenorrhea, breast tenderness and abdominal pain are more common than COCs. Breakthrough bleeding may occur in the first two cycles but is not different from COCs thereafter. Other side effects are not different from COCs.
• The most important disadvantages; partial or complete separation from the attachment site and decreased contraceptive effectiveness in obese women. Contraceptive efficacy is reduced in these women. Allergic reactions observed at the application site at a rate of 3% limit its use. The most important advantage is increased patient compliance due to the absence of daily drug use.
Vaginal Rings
• They are polymer rings that release 15 µg ethinyl estradiol and 120 µg etonorgestrel (active metabolite desogestrel). It is one of the hormonal methods with low estrogen content.
• It is applied to the vagina within 5 days following the menstrual bleeding and for 3 weeks.
stays in place. Then, it is waited for withdrawal bleeding for 1 week. If it is applied on the first day of menstruation, there is no need for an additional method. 2-5 days of menstruation. If it is started on the first week, an additional method such as a condom should be used.
• The most important disadvantage is the feeling of the ring during sexual intercourse. In this case, the ring can be temporarily removed during sexual intercourse, but must be reinserted within 3 hours.
• The use of the vaginal ring in obese women does not increase the risk of pregnancy.
Post-coital (emergency) contraception
• Precautions to be taken following unprotected coitus. Although the contraceptive effects are not fully known; delay or prevention of ovulation, deterioration of corpus luteum functions, prevention of fertilization, and in the postfertilization period, disruption of tubal motility and making the endometrium unsuitable for implantation. However, it is thought that postfertilization mechanisms are not very effective.
Methods
• Yuzpe method (estrogen + progesterone): 0.02-0.05 mg ethinyl estradiol + 0.1-0.5 mg levonorgestrel / norgestrel can be administered 12 and 24 hours after coitus. There is also a lot of nausea and vomiting.
• Oral Levonorgestrel: A single dose of 1.5 mg or 0.75 mg orally 2 times with a 12-hour interval is used. Its main mechanism of action is to delay or prevent ovulation. It is effective only if taken before ovulation and does not have an abortive effect.
• Copper IUD: Insertion of copper IUD within 5 days following coitus is the most effective emergency contraception method,
• Mifepristone (RU486) and ullipristal, which are antiprogesterone: They are very effective and has no obvious side effects. Taking it before the LH peak delays ovulation for more than 5 days and this is the primary mechanism of action. The most effective hormonal emergency contraceptive method is ullipristal.
Surgical Sterilization operations
Tubal Ligation
• It can be done during interval (nonpuerperal), postpartum or postabortus periods in terms of timing of the intervention. It is ideal for cases requiring permanent sterilization.
• The most important advantage is that it is protective against ovarian cancer and salpingitis. The most common complication is intra-abdominal adhesion.
Methods
Laparotomy (usually minilaparotomy techniques are used)
0 Pomeroy (most common, simplest)
0 Madleners (least reliable)
0 Irving and Uchida (most reliable and more difficult): No pregnancy has been reported in these two.
0 Partial and total salpingectomy
0 Cornual resection
laparoscopy
0 Spring clips (Hulka clip, Filshie clip): Most unsuccessful
0 Bipolar electrocoagulation: 2nd most unsuccessful
0 Unipolar electrocoagulation: Most successful
0 Silastic ring (Falope ring): High risk of visceral injury
Vaginal sterilization (colpotomy, culdoscopy)
0 Higher infection and failure rate
Hysteroscopic sterilization
0 Insertion of stainless steel or nickel-titanium coated coils (Essure) and insertion of a cylindrical silicon matrix after bipolar electrocoagulation (Adiana) are the most commonly used hysterescopic methods. However, both products have now been withdrawn from the market.
All pregnancies that develop after tubal sterilization should be considered ectopic until proven otherwise.
vasectomy
• A part of the vas deferens is excised and sperm passage is prevented in ejaculation. Another contraceptive method should be used within 3 months after the procedure or until azoospermia is observed in the semen sample after 13-20 ejaculations.
• Although it is possible to be reversible, the longer the time interval, the worse the prognosis.
• There is no relationship between vasectomy and vascular disease, heart disease and prostate cancer.
• The most common causes of failure are surgical technique error, unprotected intercourse in the very early period after ligation, and recanalization.
effectiveness of contraceptives
Peral index-------------------------------------------------- % Pregnancy rate during the first year
Method--------------------------------------------------------Ideal Use
Without using the method of protection ----------------► 85Spermicides -------------------------------------------------► 18
Sponge
- Multiparous woman --------------------------------------► 20
- Nulliparous woman --------------------------------------► 9
periodic deprivation
- Calendar method-------------------------------------------► 5
- Ovulation method -----------------------------------------► 3
- Symptothermal --------------------------------------------► 0.4
Diaphragm ---------------------------------------------------► 6
female condom ----------------------------------------------► 5
Withdrawal ---------------------------------------------------► 4
Male condom ------------------------------------------------► 2
Copper IUD---------------------------------------------------► 0.6
Female sterilization------------------------------------------► 0.5
Progestin only (minipill) -----------------------------------► 0.3
Combined oral contraceptive ------------------------------► 0.3
Transdermal patch -------------------------------------------► 0.3
Transvaginal ring---------------------------------------------► 0.3
Warehouse MPA ----------------------------------------------► 0.3
Levonorgesterelli IUD ---------------------------------------► 0.2
Male sterilization ---------------------------------------------► 0.1
Implant ---------------------------------------------------------►0.05
The contraceptive method with the lowest pregnancy rate; subcutaneous implants.
Pearl index: It is the number of women who get pregnant out of 100 couples using the same contraceptive method in one year.