Contraception

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  • Definition of contraception
    • A method or a system which allows intercourse and yet prevents conception is called a contraceptive method.
  • Failure rate of any contraceptive method is described in terms of pregnancy rate per 100 woman years (Pearl index).
  • Abstinence during the fertile phase
    • The calender method or the rhythm method
    • avoidance of sexual intercourse around ovulation
    • In a 28-day cycle
      • ovulation normally occurs on the 14th day of the cycle
      • ovulation may occur anytime between the 12th and 16th day (MCQ)
      • Spermatozoa deposited in the female genital tract may survive for 24 hours
      • ovum itself may live for 12 to 24 hours
      • intercourse between the 11 th and 17th day may result in a pregnancy. (MCQ)
    • Safe period
      • first day of the menstrual period until the 10th day of the cycle
      • from the 18th to the 28th day(MCQ)
    • Risk period,
      • from 3 days before ovulation to 3 days after ovulation.
      • In a 35-day menstrual cycle
        • ovulation will occur on the 21st day (that is 14 days before the next period)
        • risk period is from day 18 to day 24. (MCQ)
    • Calendar method.
      • OginoKnaus method
      • fertile peiod is determined by subtracting 18 days from the shorest cycle and 10 days from the longest cycle which gives the first and the last day of fertile period, respectively. (MCQ)
      • Failure rate : 25 pregnancies per 100 woman years.
    • Mucus method (billings or ovulation method).
      • Under oestrogen influence
        • the mucus increases in quantity
        • becomes progressively more slippery and elastic until a peak is reached
      • under the influence of progesterone
        • after peak under estrogen influence ,mucus becomes thicker, scanty and dry  until the onset of menses
      • Intercourse is considered safe during the ‘dry days’ immediately after the menses until mucus is detected. T
      • thereafter the couple must abstain until the fourth day after the ‘peak (MCQ)
    • Temperature method.
      • Progesterone is known to exert a thermogenic effect on the body.
      • BBT chart will be biphasic in an ovulatory cycle
      • day of temperature shift indicates the time of ovulation.
    • Symptothermal method.
      • This combination method is more effective.
      • The first day of abstinence is predicted either from  the calender, by subtracting 21 from the length of the shortest menstrual cycle in the preceding 6 months, or  first day mucus is detected, whichever comes first. (MCQ)
      • The end of the fertile period is predicted byuse of the ‘basal body temperature’ chart.
      • The woman resumes intercourse 3 days after the thermal shift.
    • Withdrawal method (coitus interruptus)
      • Failure rate : 25 per 100 woman years. (MCQ)
      • The main cause of the failure is not that ejaculation occurs inside the vagina but that prostatic fluid secreted prior to ejaculation, frequently contains active spermatzoa.
  • Breastfeeding
    • Regular breastfeeding with at least one feed at night is shown to prevent pregnancy for 6 months
    • failure rate of only 0.5 to 1.5%. (MCQ)
  • Barrier methods
    • Condoms        
      • water-based spermicides should be used with latex condoms
      • Because of irritation by latex in some women, non-latex polyurethane condoms are avail-able. (MCQ)
      • They however slip and break easily and are more costly than the latex condoms.
      • Latex condoms prevent STDs such as HIV
      • less protective  against STD transmitted from skin-to-skin contact such as human papilloma vims and herpes virus.
      • Nirodh brand is distributed free of cost in the government hospitals in India.
      • pregnancy rate of 10 to 14 per 100 woman years. (MCQ)
      • Other uses of condom
        • following vasecomy for 12 ejaculates(MCQ)
        • in immunological infertility
        • to prevent transmission of gonococcal, chlamydia, syphilis, trichomonad and fungal infection, HIV. (MCQ)
  • Spermicidal agents
      • contain surfactants, such as nonoxynol-9, octoxynol and menfegol (MCQ)
      • failure rate – 30 per 100 woman years. (MCQ)
      • remain effective for 1 to 2 hours after the application. (MCQ)
      • By causing irritation and abrasions in chronic use, they can cause vaginal ulceration and perhaps increase the risk of HIV spread rather than prevent it. Therefore, the sper-micidal agents should not be recommended to HIV couples. (MCQ)
      • A new spermicidal cream, Tenofovir, prevents viral attachment to the vaginal mucosa and is non-irritant and is under development. (MCQ)

Ocdusive diaphragms

      • diaphragm liberally covered with spermicide can be inserted at any convenient time left in position for a minimum of 8 hours after coitus. (MCQ)
      • It causes no discomfort
      • no douching is required
      • A refitting of the diaphragm is always required after childbirth, and this can be done about 6 to 8 weeks after confinement. (MCQ)
      • The Dutch cap or diaphragm.
        • ones in common use range between 65 and 80 mm
        • fit obliquely in the vagina, stretcing from just behind the pubic ramus into the pos¬terior fornix, thus covering the cervix.
        • It is held in position by the tension of the spring rim
        • Contraindications to use of diaphragm (MCQ)
          • prolapse, cystocele, rectocele because accurate fitting is not possible
          • recurrent urinary tract infection
          • allergy to rubber or spermicidal agent.
        • Toxic shock syndrome (TSS)
          • occur if the diaphragm is left in the vagina for a long period
          • caused by staphylococcal pyogenic infection.
        • failure rate of the Dutch cap is about 4 to 6 per 100 woman years
      • Cervical cap.
        • It fits closely to the cervix
        • suitable where the cervix is long and firm.
        • When a woman has a prolapse of uterus and vagina, a cervical cap is preferred to the vaginal diaphragm.
        • Chronic cervicitis, erosion and cervical laceration contraindicate its use.
        • available in four sizes, varying from 22 to 31 mm
      • Dumas cap
        • It is a cup-shaped rubber with a thickened rim
        • fits well into the vault of the vagina so that it encloses the cervix(MCQ)
        • size varies from 55 to 75 mm diameter.
      • Femshield (female condom).
        • known as ‘FEM’ or Femidom
        • It is a loose-fitting 15 to 17 cm long sheath
        • made of polyurethane prelubricated(MCQ)
        • It has the combined features of a diaphragm and a condom
        • It covers the entire vagina, cervix as well as the external genitalia.
        • It is highly protective against spread of STDs, and AIDS in particular(MCQ)
        • It can be removed immediately after intercourse. (MCQ)
        • Advantages of the Femshield (MCQ)
          • it is coital-independent and can be worn well in advance of the sexual act
          • it does not slip off easily, and the failure rate is expected to be low,
          • it is stronger than the condom and does not burst easily
          • it can be worn during the puerperal period unlike the diaphragm.
        • Failure rate is 5 to 15 per 100 woman years. (MCQ)
        • Femshield is expensive, costing 2 to 3 dollars per piece
        • It is not  re-usable
      • Today
        • It is a mushroom-shaped polyurethane dispo­sal sponge
        • contains 1 g of nonoxynol-9(MCQ)
        • It can remain effective for 24 hours. (MCQ)
        • Failure rate – 9 to 30 per 100 woman years(MCQ)
        • expensive, coital-dependent
        • may cause TSS if left over a long period.
    • Intrauterine contraceptive devices
      • an effective, reversible and long-term method of contraception
      • it does not require replacement for long periods
      • it does not interfere with sexual activity.
      • It is commonly made of polyethylene (MCQ)
      • It is impregnated with barium sulphate to render it radiopaque so that the presence or absence of the device in the pelvis can be easily detected by radiograph.
      • Biologically inert devices
        • indude Lippes loop and Saf-T-Coil.
        • They can be left in situ for several years, provided they cause no side effects
      • Copper carrying devices
        • copper wire of surface area 200 to 250 mm is wrapped round the vertical stem of a polypropylene frame. (MCQ)
        • Copper T 200, Copper 7, Multiload Copper 250, CopperT380, CopperT220 and NovaT.
        • have an effective life of about 3 to 5 years(MCQ)
        • It is estimated that about 50 microgms of copper is eluted daily in the uterus. (MCQ)
        • Paraguard
          • Copper T 380A (MCQ)
          • has a lifespan of 10 years. (MCQ)
        • Nova T
        • has silver added to the copper wire (MCQ)
        • lifespan is 5 years. (MCQ)
      • Progestasert and  levonova.
        • Progestasert

 

        • a T- shaped device
        • carry 38 mg of progesterone in silicon oil reservoir in the vertical stem. (MCQ)
        • It releases 65 micrograms of the  hormone  per day.  (MCQ)
        • Mechanism of contraceptive effect.

 

                • Hormone released in the uterus forms a thick plug of mucus at the cervical os which prevents penetration by the sperms
              • Menstrual problems like menorrhagia and dysmenorrhoea noticed with Copper T are less with this device (40% reduction). (MCQ)
              • Requires yearly replacement
            • Levonova
              • Contains 60 mg of levonorgestrel (LNG)
              • releases the hormone in very low doses  (20 micrograms/day). (MCQ)
              • It is longer-acting (5 years) (MCQ)
              • It has a low pregnancy rate of 0 to 3 per 100 woman years(MCQ)
              • incidence of ectopic pregnancy is sixfold to nine-fold higher in women who do become pregnant as compared to failures amongst Copper T users. (MCQ)
              • It can be safely recommended for nursing mothers. (MCQ)
            • Mirena
              • contains 52 mg LNG(MCQ)
              • elutes 20 microgram daily. (MCQ)
              • It can be retained for 5 years(MCQ)
              • It has a failure rate of 0.1 to 0.4 per 100 woman years
            • Frameless IUCD
            • IUCD under trial.
            • contains several copper cylinders tied together on a string
            • anchored 1 cm deep into fundus
          • IUCDs are a good contraceptive choice for
            • Low risk of STD
            • Multiparous woman (MCQ)
            • Monogamous relationship 
            • Desirous of long-term reversible method of contraception, but not yet desirous of permanent sterilization
            • Unhappy or unreliable users of oral contraception or barrier contraception.
          • Uses of IUCD
            • As a contraceptive
            • Postcoital contraception (emergency contraception)
            • Following excision  of uterine  septum,  Asherman’s syndrome(MCQ)
            • Hormonal IUCD (Mirena) in
              • menorrhagia and dysmenorrhea(MCQ)
              • hormonal   replacement  therapy   in menopausal women(MCQ)
              • In a woman on tamoxifen for breast cancer, it can be used to counteract endometrial hyperplasia. (MCQ)
          • Contraindications of IUCD
            • Suspected pregnancy
            • Pelvic inflammatory disease (PID)
            • lower genital tract infection
            • Presence of fibroids—because of misfit(MCQ)
            • Menorrhagia and dysmenorrhoea, if Copper T is used
            • Severe anaemia
            • Diabetic women who are not well controlled—because of slight increase in pelvic infection(MCQ)
            • Heart disease—risk of infection(MCQ)
            • Previous ectopic pregnancy(MCQ)
            • Preferably avoid its use in unmarried and nulliparous patient because of the risk of PID and subsequent tubal infertility(MCQ)
            • LNG IUCD in breast cancer    (MCQ)
            • Abnormally shaped uterus, septate uterus(MCQ)
          • Mechanism of action
              • The presence of a foreign body in the uterine cavity renders the migration of spermatozoa difficult.
              • A foreign body within the uterus provokes uterine contractility through prostaglandin release
              • It increases the tubal peristalsis (MCQ)
              • the fertilized egg is propelled down the fallopian tube more rapidly than in normal it fertilized egg reaches the uterine cavity before the development of chorionic villi and thus is unable to implant.
              • The device in situ causes leucocytic infiltration in the endometrium. (MCQ)
              • Copper T
                • elutes copper which brings about certain enzymatic and metabolic changes in the endometrial tissue which are inimical to the implantation of the fertilized ovum. (MCQ)
              • Progestogen-carrying device
                  • causes alteration in the cervical mucus which prevents penetration of sperm, in addition to its local action.
                  • It also causes endometrial atrophy(MCQ)
                  • It prevents ovulation in about 40%.(MCQ)
                      • Complications(MCQ)
                        • Immediate
                          • Difficulty in insertion
                          • Vasovagal attack
                          • Uterine cramps    
                        • Early
                          • Expulsion (2 to 5%)    
                          • Perforation (1 to 2%)
                          • Spotting, menorrhagia (2 to 10%) 
                          • Dysmenorrhoea (2 to 10%)
                          • Vaginal infection    
                          • Actinomycosis      
                        • Late                                    
                          • PID—-2 to 5%.
                          • IUCD does not prevent transmission of HIV.
                          • Pregnancy— 1 to 3 per 100 woman years (failure rate)
                          • Ectopic pregnancy
                          • Perforation  
                          • Menorrhagia 
                          • Dysmenorrhoea.
                      • IUCD can be inserted in HIV-positive woman on medication. (MCQ)
                        • Long-term follow-up of women wearing IUCD has shown no ill effects on systemic diseases.
                        • There is no evidence that the device predisposes to either cervical or endometrial cancer.
                      • Perforation
                        • can occur at the time of insertion, particu-larly during puerperium
                        • rare with withdrawal than push-in technique(MCQ)
                      • Menorrhagia is controlled with NSAID drugs.
                      • Expulsion
                        • may occur in 5 to 15%
                        • due to small size of IUCD
                        • common during the puerperal period or following MTP of a large gestation size. (MCQ)
                      • PID
                        • occurs usually in the 4 weeks of insertion
                        • Actinomycosis is an infection commonly associated with IUCD.
                      • Misplaced IUCD     
                        • the tail of the IUCD is not seen through the os
                        • causes are(MCQ)
                          • uterus has enlarged through pregnancy
                          • thread has curled inside the uterus
                          • perforation has occurred
                          • IUCD is buried in the myometrium
                          • it has been expelled
                        • A plain radiograph or pelvic ultrasound is used to diagnose
                        • If it is inside, the uterine sound or another IUCD inserted in the uterine cavity will show on radiograph its proximity to the misplaced IUCD and perforation can be diagnosed
                        • Abnormal shape or location of IUCD on radiograph indicates likely perforation.
                        • Hysteroscopy is useful not only to locate it but also for its retrieval
                        • If the IUCD is in the uterine cavity, it can be retrieved with Shirodkar’s hook, a curette or through a hysteroscope.
                        • In case of perforation, a laparotomy is needed, because Copper T causes adhesions to the omentum or a gut and cannot be retrieved easily through a laparoscope.
                      • Pregnancy.
                        • occurs with IUCD in situ in 1 to 3 per 100 woman years.
                        • If this happens, it is important to do ultrasound and rule out ectopic pregnancy(MCQ)
                        • The uterine pregnancy can cause severe infection
                        • It is therefore mandatory to remove the IUCD if the tail is visible through the os. While doing so, the risk of abortion should be explained to the woman.
                        • If the thread of the IUCD is not seen, termination of pregnancy is offered, not because IUCD has any teratogenic effect but because the risk of uterine infection is considerable. (MCQ)
                      • Ectopic pregnancy
                        • It occurs in 1:30 pregnancies in woman wearing IUCD.
                        • because IUCD has a local contraceptive action on the uterus and prevents a uterine pregnancy but does not protect against tubal or ovarian pregnancy
                        • Progestasert has the highest incidence of ecto-pic pregnancy (six to nine times more than Copper T). (MCQ)
                        • PID also contributes to the occurrence of an ectopic pregnancy.
                      • Advantages of IUCD
                        • It is coital-independent. (MCQ)
                        • newer IUCDs being as effective as oral contraceptives.
                        • hree per cent failure rate at the end of 1 year is reduced to less than 1% at the end of 5 years.
                        • There is no user failure. (MCQ)
                        • There is no evidence of reduced fertility following its removal.
                        • About   75%   women   conceive   within   6 months  of its removal
                        • almost 90%  conceive within a year. (MCQ)
                        • There are no systemic ill effects, unlike oral contraceptives
                        • No adverse effect on lactation is observed.
                        • Copper T is inserted free of cost in government hospitals in India. (MCQ)

                       

                        • Minipill/progestogen-only pill (POP)
                          • The low-dose POP  (MCQ)
                          • norethisterone 350 mcg, norgestrel 75 mcg or LNG 30 mcg
                          • tablet is taken daily without a break(MCQ)
                          • The pill should be started within 5 to 7 days of the menstrua-tion
                          • taken at the same time with a leeway of 3 hours on either side of the fixed time each day. (MCQ)
                          • If this regime is not observed any day, the woman cotinues with POP but observes extra precaution for 48 hours. (MCQ)
                          • POP is started 21 days postpartum and soon after abortion.
                          • woman needs to take precaution in the first 48 hours in the first cycle.
                          • it is well suited for lactating women ,some progestogens, in fact, increase milk secr-tion.
                          • it has a pregnancy rate of 2 to 3 per 100 woman years which is higher than that of the COCs though comparable to an IUCD and is higher in obese women(MCQ)
                          • Drawbacks(MCQ)
                            • Strict daily compliance is a drawback
                            • irregular bleeding (20%), amenorrhoea
                            • depression, headache
                            • migraine and weight gain,
                            • ectopic pregnancy, besides a higher failure rate.
                          • The use of newer generation of synthetic progestogen, namely desogestrel, has been encouraging.
                          • It has no androgenic effect(MCQ)
                          • no adverse effect on carbohydrate and lipid metabolism(MCQ)
                          • considered to be safe, especially for women over 40 years and lactating women. incidence of thromboembolism is higher with these progestogens.
                          • Contraindications to POP  (MCQ)
                            • previous ectopic pregnancy, ovarian cyst
                            • breast and genital cancers
                            • abnormal vaginal bleeding, active liver and arterial diseas
                            • porphyria, liver tumour
                            • valproate, spirono-lactone and meprobamate.
                          • Advantages of POP are that they can be recommended to: (MCQ)
                            • Lactating women
                            • Women over 35 and smokers
                            • Those with focal migraine       ‘
                            • Intolerant to oestrogen or oestrogen contraindicated
                            • Diabetic, hypertensive woman, sickle cell anaemia.
                          • As regards to return of fertility, it is faster than in COC users because ovulation is not suppressed in all cases (suppressed in 40%).
                        • Cerozette
                          • contain 75 mcg desogestrel (MCQ)
                          • Advantages over other POPs: (MCQ)
                            • Stringent time compliance not necessary, as it supresses ovulation in 97%, through pituitary hormone suppression
                            • No androgenic effects like acne.
                            • No ectopic pregnancy
                            • no effect on carbohydrate or lipid metabolism.          :
                            • Failure rate only 0.21 per 100 woman years
                            • It acts through metabolite etonogestrel which binds to progesterone receptors
                          • Complications of desogestrel are(MCQ)
                            • Deep venous thrombosis
                            • Pulmonary embolism, breast cancer, liver disease apart from common complications of progestogens.
                        • Depot injections
                          • Include (MCQ)
                            • Depotmedroxyprogesterone acetate (DMPA)  given in microcrytalline aqueous suspension
                            • norethisterone enanthate (NETO) in castor oil solution
                          • both by deep intramuscular injection (not subcutaneous).
                          • A monthly injection of DMPA 25 to 50 mg, combined with 5mg oestradiol is considered to be effective.
                          • Other preparations in use are
                            • DMPA 150 mg three-monthly
                            • DMPA 300 mg six-monthly
                            • NETO 200 mg two-monthly.
                          • After stoppage, the contraceptive effect of DMPA lasts longer than that of NETO. (MCQ)
                            • Menstrual irregularity is accepted by puerperal woman as physiological.
                            • injection should be started within a month of delivery in a non-lactating woman and during the third month in a lactating woman because ovulation is delayed up to at least 10 weeks in lactating mothers.
                          • Pregnancy rate is (MCQ)
                            • 0.4 per 100 woman years for DMPA
                            • 0.6 per 100 woman years for NETO.
                          • The injection should be administered within 7 days of menstruation with grace period of 2 weeks for DMPA and 1 week for NETO (12 to 14 weeks of first injection for DMPA and 8 to 9 weeks for NETO).
                          • Advantages(MCQ)
                            • are easy to administer and there is no worry over ‘missing pill’.
                            • The compliance is good and the woman remains under regular medical supervision.
                            • The side effects of lipid and carbohydrate metabolism are avoided.
                            • DMPA is least androgenic. (MCQ)
                            • It is suited to lactating women.         .
                            • The incidence of PID, ectopic pregnancy and functional ovarian cysts is low, so also endometrial cancer.
                            • Avoids oestrogenic side effects.
                            • Can be given to a woman with sickle cell anaemia.
                            • Return of fertility is slightly delayed in DMPA group compared to NET, but 80% conceive in 1 year. (5 months for DMPA and 3 to 4 months for NETO).
                            • Coital independent
                          • Disadvantages(MCQ)
                            • Once administered, the side effects, if any, need to be tolerated until the progestogenic effect of the injection is over
                            • Menstrual   irregularity  occurs   and   amenorrhoea  is reported in 20 to 50% at end of 1 year, more with DMPA than NET
                            • Heavy bleeding is reported in 1 to 2% users.
                            • There is a delay in return of fertility but 80% are expected to conceive by end of 1 year.
                              • With DMPA, ovulation returns in 5 months
                              • with NETO, within 3 months of the last injection.
                            • The side ‘effects of weight gain, depression, bloated feeling   and   mastalgia   can   occur  with   injectable progestogen.
                            • Prolonged DMPA use, by virtue of antioestrogenic action, may reduce bone density mass and induce osteopenia.
                            • Contraindicated in breast cancer(MCQ)
                            • It does increase LDL but does not adversely affect the blood pressure.
                            • Because of risk of osteopenia, this contraceptive is(MCQ)
                              • contra-indicated in adolescents
                              • not more than 2 years should be in use in others
                        • Subdermal implants
                          • have no ‘nuisance value’ of continuous compliance which often adversely affects motivation.
                          • non-oral system avoids ‘hepatic first pass effect and systemic side effects’. (MCQ)
                          • Norplant II
                            • consists of two rods each containing 70 mg LNG.
                            • daily release of hormone is 50 mcg
                            • provides contraception for 3 to 5 years. (MCQ)
                            • main action is suppressing endometrium.
                            • The implants suppress ovulation in 50%
                            • implants are inserted on the (MCQ)
                              • first day of the menstrual cycle
                              • within 5 days of abortion
                              • 3 weeks after the delivery.
                            • The woman needs to use barrier contracep-tion or abstain in the first 7 days of insertion. (MCQ)
                            • It is best inserted on the medial aspect of the upper arm under local anaesthesia.. (MCQ)
                          • Implanon
                            • single rod,
                            • contains 67 mg desogestrel(MCQ)
                            • It elutes 30 mcg of the hormone daily
                            • effect lasts 3 years. (MCQ)
                            • It prevents ovulation
                            • Fertility reversible within 1 month of removal
                          • Capronor
                            • a biodegradable single capsule (MCQ)
                            • contain LNG (MCQ)
                            • does not require removal.
                            • Ten per cent women request removal at the end of 1 year because of side effects.
                            • return of fertility occurs in  – 90% conceive in 2 years.
                          • Contraindications of implants are
                            • Breast cancer, liver .disease, arterial disease
                            • porphyria and previous ectopic pregnancy
                          • Advantages of implants are:
                            • They are long-acting with sustained effect—compliance is good.
                            • Coital-independent with no ‘nuisance’ of daily oral or frequent injections.
                            • Pregnancy rate
                              • Varies between 0.2 and 1.3 per 100 woman years
                              • higher in obese women weighing more than 70-kg.
                            • Systemic side effects are few
                            • first pass effect on the liver avoided.
                            • Can be used by lactating mothers and over the age 40. (MCQ)
                          • Disadvantages of implants are
                            • Breakthrough bleeding, irregular cycles
                            • Amenorrhoea occur as with other progestogenic contraceptives. (MCQ)
                            • Ectopic pregnancy is reported in 1.3%
                            • Local infection may occur
                            • The implants are expensive and cost Rs 10,000.
                            • Infertility is seen in a few cases.
                          • Silastic vaginal rings (SVR)     
                            • The ring is 50 to 75 mm in diameter a
                            • releases 20 mcg of LNG daily. (MCQ)
                            • contraceptive effect is mainly on the cervical mucus.
                            • It is kept in situ for 3 weeks and removed for a week, thus bringing about regular menstrual cycles
                            • failure rate is 1.8/100 woman years.
                            • Nestorone ring (MCQ)
                              • releases 150 mcg progestogen plus 15mcg oestradiol daily
                              • one ring remains effective for 1 year.
                            • Nuvaring(MCQ)
                              • 120 ug   etonogestrel + 15 ug   EE2   daily
                              • release can be removed during intercourse but not for more than 3 hours at a time.       
                          • Centchroman      
                            • released in India under the name of Saheli. (MCQ)
                            • a synthetic non-steroidal contraceptive (MCQ)
                            • taken as a tablet 30 mg started on the first day of menses
                            • taken twice weekly for 12 weeks and weekly there-after
                            • half-life is 170 hours
                            • It prevents implantation through endometrial changes.
                            • It exhibits a strong anti-oestrogenic and a weak oestrogenic action peripherally at the receptor level.
                            • The return of-fertility occurs soon after stoppage of the drug (within 6 months). (MCQ)
                            • not teratogenic or carcinogenic
                            • exerts no pharmacological effect on other organs.
                            • The only side effect noted is prolonged cycles and oligomenorrhoea in 8% cases. (MCQ)
                            • This is due to prolonged proliferative phase
                            • Pregnancy rate is 1.83 per 100 woman years.
                            • The drug can also be used as a postcoital pill(MCQ)
                            • given in 60 mg dose within 24 hours of coitus
                            • 2 tablets repeated 12 hours later (MCQ)
                            • failure rate of 1%
                            • Side effects
                              • Headache, nausea, vomiting:
                              • Gain in weight.
                              • Some delay in return of fertility.
                            • Contraindications(MCQ)
                              • During 6 months of lactation.
                              • PCOD, hepatic dysfunction, cervical dysplasia
                              • Allergy to the drug
                        • Postcoital contraception (interceptives) (MCQ)
                          • Postcoital contraceptive agents interfere with postovulatory events leading to pregnancy and are therefore known as interceptives.
                          • also known as ’emergency contraception’ method used to prevent pregnancy after an unprotected intercourse
                          • Yuzpe Regimen (MCQ)
                            • Two tablets of relatively high doses of combined pill containing 100 mcg EE2 and 1 mg norethisterone, or 500 mcg LNG, taken within 72 hours of intercourse followed by 2 tablets taken 12 hours later (Yuzpe and Lancee, 1977).
                            • Failure rate—3.2 per 100 woman years.
                          • Haspels Method
                            • Ethinyloestradiol 1 mg daily for 5 days, starting within 72 hours of exposure
                            • Failure rate – 0 to 1.5%
                          • LNG
                            • Mechanism
                              • delay ovulation if taken soon after intercourse
                              • cause corpus luteolysis(MCQ)
                              • bring about cervical mucus changes and endometrial atrophy.
                            • Levonorgestrel (LNG) tablet contains 0.75 mg LNG.
                              • One tablet should be taken within 72 hours of unprotected intercourse and another 12 hours later(MCQ)
                              • Alternately two tablets can be taken as a single dose(MCQ)
                            • The failure rate is 1.1%.
                            • The tablets can be offered up to 120 hours but its efficacy decreases with the longer coital-drug interval.
                            • Side effects are those of progestogens.
                            • The hormone is not teratogenic in case pregnancy does occur but risk of ectopic pregnancy remains. (MCQ)
                            • Advantages
                              • It has no oestrogen and its associated side effects.
                              • It can be offered to hypertensive, cardiac and diabetic woman. (MCQ)
                              • It can be offered to a lactating woman.
                              • It can be given as late as 120 hours after the unprotected intercourse. (MCQ)
                              • Single-dose therapy is an advantage.
                            • The drug is contraindicated in a woman with history of thrombophlebitis and migraine.
                          • RU 486 (mifepristone)
                            • RU 486 is a steroid with an affinity for progesterone receptors
                            • It does not prevent fertilization (MCQ)
                            • It blocks the action of progesterone on the endometrium it causes sloughing and shedding of decidua and prevents implantation. (MCQ)
                            • It is not teratogenic.
                            • A single dose of 10 mg is effective in preventing pregnancy in
                            • Failure rate–  0.9%
                            • It causes delayed menstruation
                            • Ectopic pregnancy is not avoided.
                          • Ulipristal              ,    :
                            • Ulipristal is a synthetic progesterone hormone receptor modular(MCQ)
                            • attaches to progesterone receptor and prevents/ delays ovulation and suppresses endometrium, prevents implantation(MCQ)
                            • A 30 mg tablet should be taken within 5 days
                            • Failure rate – Two per cent
                          • Centchroman
                            • Two tablets (60 mg) taken twice within 24 hours of intercourse can prevent implantation (MCQ)
                            • Failure rate – one percent
                          • Copper-IIUCD    ,           :           ;           ;,.
                            • Inserted within 5 days of intercourse can prevent implantation of a fertilized ovum. (MCQ)
                            • Advantages of Copper T as emergency contraception (MCQ)
                              • It can be inserted as late as 5 days after the unprotected intercourse. (MCQ)
                              • It is cheap.           
                              • Failure rate is 0.1%.     
                              • It can remain as ongoing contraceptive method for 3 to 5 years.

                     

                      • Mirena lUCD
                            • contain LNG progestogen in a silastic reservoir
                            • 20 microgram hormone is eluted in 15 minutes after its insertion (MCQ)
                            • peak level reaches in a few hours.
                            • The hormone does not get absorbed into the general circulation (or minimal amount) so the side effects of systemic administrations are not seen.
                            • It does not suppress ovulation(MCQ)
                            • Its effect is mainly on the endometrium and cervical mucus.
                            • Because of this, Mirena is also used in (MCQ)
                              • dysfunctional uterine bleeding (DUB)
                              • endometrial hyperplasia
                              • in HRT
                              • in a woman on tamoxifen for breast cancer to combat hyperplasia of endometrium caused by oestrogen.
                            • The pregnancy rate is 0.5 per 100 woman years (equal to that of tubectomy).
                            • Teratogenic if pregnancy occurs with Mirena in situ due to progestogen. (MCQ)
                            • Incidence of ectopic pregnancy 0.02%.
                            • As compared to tubectomy, Mirena is an effective contraceptive but is reversible, reduces dysmenorrhoea and menorrhagia unlike tubectomy. (MCQ)
                            • Mirena, since it cures menorrhagia and is as effective as tubectomy, is expected to reduce the number of hysterectomies and tubectomy operations in future.
                      • Suppression of spermatogenesis
                        • Gossypol(MCQ)        
                          • use as a male contraceptive
                          • a yellow pigment isolated from cottonseed oil.
                          • action is directly on the seminiferous tubules inhibiting spermatogenesis without altering FSH and LH levels. (MCQ)
                          • side effects such as weakness, hypokalaemia (MCQ)
                          • permanent sterility in 20% cases limit its use.
                        • Testosterone enanthate   
                          • effective through negative feedback mechanism.
                        • GnRH
                          • The continuous administration of analogues of GnRH causes a fall in the sperm count and sperm motility
                          • loss of libido and osteoporosis makes this regime unacceptable over a long period.
                        • Medroxyprogesterone acetate
                        • Desogestrel       
                      • Suppression of ovulation (hormonal contraceptive agents)
                        • In 1956 , Pincus first brought out an oral contraceptive drug
                        • three types of hormonal oral contraceptives,
                          • combined oral pills
                          • triphasic combined pills
                          • minipills.        
                        • Combined oral pills
                          • contain a mixture of ethinyloestra-diol (EE2) in a dose of 20 to 30 mcg and an orally active progestogen which is a 19-norsteroid(MCQ)
                          • OCPs available free of cost in India.
                            • Mala-D  contains 0.5 mg of d-norgestrel (MCQ)
                            • Mala-N contains 1 mg norethisterone; (MCQ)
                          • Regime of taking COCs
                            • tablets are taken starting on the second day of the cycle for 21 days. (MCQ)
                            • A new course of tablets should be commenced 7 days after the cessation of the previous course. (MCQ)
                            • starting the pill on the first day of the cycle has reduced the failure rate
                            • They should be taken at a fixed time of the day, preferably after a meal.
                          • Mechanism of action of COCs
                            • COC suppresses pituitary hormones, FSH and LH, peak and through their suppression prevents ovulation (MCQ)
                            • At the same time, progestogen causes atrophic changes in the endometrium and prevents nidation.
                            • Progestogen also acts on the cervical mucus making it thick and tenacious and impenetrable by sperms.
                            • It also increases the tubal motility, so the fertilized egg reaches the uterine cavity before the endometrium is receptive for implantation.
                          • Pregnancy rate with COC is 0.1 per 100 woman years, which is the lowest of all contraceptives in use today. (MCQ)
                          • During the first cycle of use, ovulation may not be suppressed and the patient is advised to use an addi-tional method to prevent pregnancy.
                          • If she forgets to take a tablet, she should take 2 tablets the following day. (MCQ)
                          • If she forgets to take the tablet more than once in a cycle, she is no longer adequately protected and must use a barrier method during that cycle. (MCQ)
                          • The majority of failure with COCa are due to the failure to take the pills regularly.
                          • With proper compliance, most women have regular 28-day menstrual cycles.
                          • The bleeding is less in amount and shorter in duration than,a normal menstrual period.
                          • In a non-lactating woman, OC can be started after three weeks of delivery, but can be given soon after an abortion, MTP or an ectopic pregnancy. (MCQ)
                          • Following hydatid mole, one should start on OC only after serum Beta-hCG is negative. (MCQ)
                          • HIV antiviral drugs reduce effectiveness of OC but combined with condoms it is protective against pregnancy.
                          • Benefits of combined pills (MCQ)
                            • As it causes regular and scanty menstruation, it is useful in menorrhagia and polymenorrhoea. (MCQ)
                            • By virtue of non-ovulation, it can relieve dysmenorrhoea and premenstrual tension. (MCQ)
                            • It prevents anaemia by reducing the menstrual loss.
                            • It has proved to lower the incidence of benign breast neoplasia. (MCQ)
                            • It reduces the incidence of functional ovarian cyst (50%) and ovarian and uterine malignancy. (MCQ)
                            • The incidence of ovarian cancer is reduced by 40% and uterine malignancy by 50% if taken for 1 year, and this effect lasts  as long as  10 years after stoppage.
                            • The incidence of PID is reduced, though it does not reach the same low level as seen with the barrier method. (MCQ)
                            • This effect is due to the thick cervical mucus caused  by  progestogen,   preventing  the   organisms entering into the uterine cavity.
                            • Reduced incidence of ectopic pregnancy is due to suppression of ovulation and reduction in PID. (MCQ)
                            • It protects against rheumatoid arthritis. (MCQ)
                            • Reduces the risk of anorectal cancer by 30 to 40%.(MCQ)
                            • It is useful in acne, PCOD and endometriosis. (MCQ)
                          • Side effects and contraindications
                          • Intermenstrual   spotting   is   common   in   the   first 3 months of the start of the pills but it gradually disappears. (MCQ)
                          • Heavy spotting can be stopped by increaing the dose for a few months.
                          • Menstrual bleeding
                            • can become very scanty and occasionally a woman becomes amenorrhoeic causing undue fear of pregnancy
                            • Amenorrhoea of 6 months requires investigations.
                            • Post-pill amenorrhoea is not related to the type, dose or duration of pill intake. (MCQ)
                            • Those with previous menstrual irregularity (oligomenorrhoea) are likely to suffer amenorrhoea.
                          • Genital tract
                            • associated with monilial vaginitis. 
                            • Carcinoma   of the   endocervix  has  been reported if used for more than 5 years cervical dysplasia is more frequent. (MCQ)
                            • No adverse effect is noted on uterine fibroids
                          • Breast.
                            • COCs should not be offered to a woman suffering from cancer of the breast.
                            • Some have reported the breast cancer in a nulliparous woman who has taken COCs before the age of 24 years for over a period of 4 years(MCQ)
                            • If at all breast cancer develops, it is well differentiated with good prognosis
                            • The risk of malignancy disappears after 10 years of stoppage. (MCQ)
                          • Pituitary adenoma was attributed to the use of the pill
                          • Lactation is suppressed with combined pills.
                            • The combined pills are therefore contraindicated in a lactating mother.
                            • the risk of thromboembolism is highduring puerperium.
                            • Libido varies and may not be related to the pills. (MCQ)
                            • Nausea and vomiting are mainly due to oestrogen
                            • It can be avoided by taking the pills at bedtime.
                          • Liver
                            • Adenomas have been reported
                            • hormones are metabolized in the liver, chronic liver diseases and recent jaundice contraindicate the use of pills. (MCQ)
                            • Gall bladder function may be adversely affected. (MCQ)
                          • COCs are contraindicated or cautiously given to a diabetic woman. (MCQ)
                          • Lipid metabolism.
                            • Oestrogen increases the HDL  and lowers LDL(MCQ)
                            • Some progestogens  have  a reverse effect
                          • Drugs   interfering  with   COC   (MCQ)
                            • Tetracycline ,anticonvulsants , Rifampicin
                            • antifungal, cephalosporin and phenobarbital
                          • Headache, migraine, depression, irritability, increased weight and lethargy  due to progestogen. (MCQ)
                          • Thromboembolic  disorders
                            • Pulmonary  embolism and cerebral thrombosis
                            • both venous and arterial, are seven to ten times more frequent in the pill users than in the non-users.
                            • caused by the oestrogen component of the pill.
                            • The effect is dose-dependent
                            • reduction of the oestrogen content of the pill from the original 100 to 30 pg, (MCQ)
                          • Newer oral pill – Femilon
                            • contains desogestrel 0.15 mg, ethinyl estradiol 0.02 mg. (MCQ)
                            • 20 micrograms  EE2 improves safety and tolerance profile(MCQ)
                            • high-risk cases for this complication of thromboembolic  disorders due to pills(MCQ)
                              • A woman over 40 years
                              • a woman with stroke
                              • heavy smoker
                              • cardiac and hypertensive patient
                              • a woman with famlial hyperlipoproteinaemia
                            • The pills containing desogestrel and gestodene (third generation) carry a higher risk of venous thromboembolism than the pills containing LNG. (MCQ)
                            • Sickle cell anaemia can cause thrombosis and crisis.
                            • A woman who wears contact lenses should be warned of oedema and irritation of eyes (thrombosis of optic vessels)—it is a relative contraindication
                            • COC   pill   does  not  protect  a woman against HIV and STIs(MCQ)
                            • No adverse effect on thyroid.
                          • COCs are contraindicated in:
                            • Cardiac disease, hypertension, smoker over 35 years.
                            • Diabetes.  (MCQ)
                            • History of thrombosis, myocardial infarct, sickle cell anaemia, severe migraine. (MCQ)
                            • Chronic liver diseases such as cholestatic jaundice of pregnancy, cirrhosis of liver, adenoma, porphyrias.
                            • Breast cancer, thyroid disease.
                            • Gross obesity.
                            • Patient on enzyme-inducing drugs like rifampicin, and antiepileptic except sodium valproate.
                            • 4 to 6 weeks prior to planned surgery. (MCQ)
                            • Lactating woman.
                            • Monilial vaginitis. (MCQ)
                          • Return of menstruation and fertility
                            • 90% will have normal menstmal cycles within 6 months of stopping OC(MCQ)
                            • no evidence of fetal malformation or increased rate of abortion in those who conceive while on pills.
                            • Ninety per cent ovulate within 3 months of stoppage of drug. (MCQ)
                        • Triphasic combined pills
                          • The triphasic preparations of EE2 and LNG contain (MCQ)
                            • during the first 6 days of the cycle 30 mcg EE2 plus 50 mcg LNG
                            • for the next 5 days 40 mcg EE2 plus 75 mcg LNG
                            • during the last 10 days 30 mcg EE2 and 125 mcg LNG
                            • followed by one medication-free week.
                          • These pills have no adverse effect on carbohydrate and lipid metabolism(MCQ)
                          • can be prescribed to diabetic women and without expecting any increased risk of myocardial infarct. (MCQ)
                          • They are as effective as the monophasic oral pills
                          • They are not recommended in menorrhagia and for other indications.
                        • New ORAL PILLS
                          • Once-a-month   pill 
                            • contains   3 mg   quinestrol   and 12 mg megestrol acetate(MCQ)
                            • Two tablets in first month are followed by one tablet monthly.
                          • EE2 + drospirenone (Yasmin, Tarana, Janya) contain 21 tablets in a packet, but Janya contains 24 tablets (gap of four tablets in a cycle). (MCQ)
                          • EE2 + cyproterone acetate (Dianette). (MCQ)
                          • Drospirenone
                            • an analogue of spironolactone
                            • is anti-mineralocorticocoid and with anti-androgenic activity(MCQ)
                            • It inhibits ovulation, cures acne and hirsutism
                            • It reduces fluid and sodium retention
                            • it has no adverse effect on bone mineral density
                            • It also prevents obesity and maintains good lipid profile. (MCQ)
                            • Because of this and cure of acne, it is also known as’beauty pill. (MCQ)
                            • Side effects are: (MCQ)
                              • Potassium retention
                              • It is contraindicated in renal and liver disease and in a woman with previous thromboembolism.
                          • Different generations of oral pills(MCQ)
                            • First generation contained norethindrone.         ,’
                            • Second generation contained LNG.
                            • Third  generation  contained  gestodene,   desogestrel, norgestimate.
                            • Fourth generation contains spironolactone and cyproterone acetate.
                          • Janya contains 24 tablets, each containing 20 ug EE2 and 3 mg drospirenone. (MCQ)
                          • Yasmin contains 30 ug EE2 with same dose of latter. (MCQ)


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