[GYNE] Family Planning (Ona Cruz, 2021) PDF

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Page 1 of 8 Sources: Dr. J. Ona Cruz’s 2021 lecture, Comprehensive Gynecology 7th Edition Chapter 13, PARBSPART 1TYPES OF FAMILY PLANNINGReversible Methods Permanent Methods Fertility, or the ability to reproduce is restored once discontinued ✓ Spermicides ✓ Barriers ✓ Oral Contraceptive Pills ✓ Lon...

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PART 1  Contracept Contraceptive ive Overview • Each of the currently available methods of contraception has distinct advantages and disadvantages • Clinicians: o should be able to explain the unique features of each method o must also evaluate whether medical contraindications to a particular method exist for a woman and offer her safe and effective alternatives • Health risks associated with unintended pregnancy must always be considered in the medically challenging patient • In general, the best method for an individual is one that is relatively safer than pregnancy and that will be used correctly and consistently.

• Contraceptive Failure Rate ▪ Pregnancy rates with various types of contraceptions at different intervals or years ▪ Number of pregnancies per 100 women at 1 year • Pearl Index ▪ pregnancy rate computed at # of pregnancies x 1200 over woman months of use # 𝑜𝑓 𝑝𝑟𝑒𝑔𝑛𝑎𝑛𝑐𝑖𝑒𝑠 𝑥 1200 𝑃𝑟𝑒𝑔𝑛𝑎𝑛𝑐𝑦 𝑅𝑎𝑡𝑒 = 𝑚𝑜𝑛𝑡ℎ𝑠 𝑜𝑓 𝑢𝑠𝑒

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• • In the Philippines, giving birth KILLS. • Maternal mortality rates for women 15-49 years old is at 19.8%. • Neonatal, infant, child, and under-five mortality rates are at 14%, 8%, 22% and 8% respectively.  RA 10354 • An Act Providing for a Natio National nal Policy o on n Responsible Parenthood and Reproductive Health (December 21, 2012) • Enables couples and individuals to decide freely and responsibly the number and spacing of their children • To have the information and means to do so • To have access to a full range of safe, affordable, effective, nonabortifacient modern natural and artificial methods of planning pregnancy TYPES OF FAMILY PLANNING Reversible Method Methods s Permanent Metho Methods ds • Fertility, or the ability to • Entail minor procedures reproduce is restored once • Can now be re-anastomosed, discontinued but success rate for future ✓ Spermicides pregnancies are at best 50%, ✓ Barriers depending on the state of ✓ Oral Contraceptive Pills damage and the skill of the ✓ Long Acting Hormonal surgeon. Contraception ✓ Vasectomy for males ✓ IUD or IUS ✓ Bilateral Tubal Ligation for females CONTRACEPTIVE EFFECTIVENESS

Indices of Effectiveness: • Typical Use Effectiveness (Use) ▪ Overall rate of effectiveness in actual use of a particular contraceptive method taking into consideration human errors (inconsistent or incorrect use) • Perfect Use Effectivenes Effectiveness s (Method) ▪ Rate of effectiveness of a contraceptive when it is always use correctly and consistently (no human error)

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REVERSIBLE METHODS Spermicides Consist of an active agent and a carrier o Carrier: gels, foams, creams, tablets, films, and suppositories o Active agent: nonoxynol-9 (same for all) − a surfactant that immobilizes or kills sperm on contact by destroying the sperm cell membrane Coitus-related o must be placed into the vagina only before each coital act o the contraceptive sponge, a cylindric piece of soft polyurethane impregnated with 1 mg of nonoxynol-9 spermicide, must be inserted into the vagina before intercourse and is effective for 24 hours Used with barriers to increase effectiveness Failure rate: 15% to 25% Adverse effect : No increased risk for congenital malformations or chromosomal anomalies

 Ways to Apply Spermicide: a.) Simplest way: put spermicide on the fingertips, then insert the finger and apply the spermicide near the vicinity of the cervical os b.) With the use of applicator or syringe: more sanitary. Apply the spermicide near the vicinity of the cervical os.

Barrier Met Methods hods ✓ Diaphragm ✓ Male Condom ✓ Cervical Cap ✓ Female Condom Diaphragm • A thin, dome-shaped membrane of latex rubber or silicone with a flexible spring modeled into the rim o The concave portion is where the spermicide is placed and then put against the cervical opening o The spring allows the device to be collapsed for insertion and then allows for expansion within the vagina to seat the rim against the vaginal wall • Lodged or set in place by the vaginal fornices • Objective: provide a barrier or occlusion so the sperm cannot enter the cervical opening • Needs fitting for the appropriate size o Too large: ▪ uncomfortable for the patient ▪ can cause pressure on the nearby structures (anteriorly to the urethra, which may lead to urine outflow obstruction then eventually UTI) o Too small: may get dislodged

Sources: Dr. J. Ona Cruz’s 2021 lecture, Comprehensive Gynecology 7th Edition Chapter 13, PARBS |

 Proper Use of a Diaphragm: • Apply spermicide directly on the concave portion of the diaphragm • Instruct the patient to assume an upright position, one leg slightly raised • Insert the diaphragm way up the vaginal canal at the region of the fornices

• Diaphragm is left in place 4-6 hours (book: at least 8 hours) after coitus, but should not be left in the vagina for >24 h hours ours ours. o If not removed within 24 hours, it may induce ulceration in the vaginal mucosa, which can be a nidus of infection • Advantages: ✓ Safe, reversible ✓ Married, motivated women ✓ Failure rates (high during first year of use) decrease with age and duration of use • Adverse Effects: ✓ UTI ✓ Vaginal epithelial ulcerations Cervical Cap • A cup-shaped silicone or rubber device that fits around the cervix • Should be fitted to the cervix o Available in 3 sizes ▪ Small (22mm) ▪ Medium (26mm) ▪ Large (30mm) • Objective: provide a barrier so the sperm cannot enter the cervical opening • Should not be left in the vagina for >48 hours • Normal cervical cyt cytology ology required because it has been associated with abnormal cytology • Pap test t hree months after to monitor development of dysplastic changes in the cervix

• From the book: The diaphragm and cervical cap may also reduce the risk of cervical dysplasia and cancer. • Advantages: ✓ Safe and reversible ✓ Good continuation rates ✓ Placed longer than diaphragm ✓ More comfortable because of its smaller size • Adverse Effects: ✓ If left in place >48hours: o mucosal ulcerations o unpleasant odor o infection ✓ Adverse effects on cervical tissue Male Condoms • Latex, polyurethane, or animal tissue • Most effective contraceptive method to prevent transmission of STDs (latex, polyurethane), but still does not provide 100% protection • Ideal for males with multiple sex partners • Advantages: ✓ Safe, reversible ✓ Prevent STD transmission ✓ Highly effective for motivated user

 Proper Use of Male Condom: • Put the condom as soon as erection occurs before any contract with the vagina or vulva • Tip should extend beyond the end of the penis by about half an inch to collect the ejaculate • Do not remove mid-coitus • After ejaculation, the penis must be removed from the vagina while still somewhat erect, and the base of the condom grasped to ensure the condom is removed without spillage of the ejaculate  Do not recycle your con condoms! doms! Dispose in a sanitary way.  Water-based lubrication may reduce condom breakage. Do not use oil-based lubricants as they may weaken the condom.  Never use an exp expired ired cond condom! om! If the package is not opened, condoms are good up to 5 years after the manufacture date. Expired condoms may have microtears already. Female Condom • Less commonly used because: o Expensive o Squeaky • Consists of a soft, loose-fitting polyurethane sheath with two flexible rings o Inner ring (closed end) is placed high up inside the vagina and lodged into the fornices o Outer ring remains outside the vagina and covers the perinium, providing protection from HPV infection (if male partner has genital warts)

• Advantages: ✓ Fitting not needed ✓ Can be inserted before starting sex ✓ Can be left in place for a longer time after ejaculation but not beyond 24-48 hours ✓ Additional protection for external genitalia ✓ Less likely to rupture than male condom ✓ Also reduces risk for HIV and HPV  Advantages of Barriers: ✓ Reduction of STD transmission especially if used with spermicides ✓ Protection against salpingitis and cervical neoplasia

Sources: Dr. J. Ona Cruz’s 2021 lecture, Comprehensive Gynecology 7th Edition Chapter 13, PARBS |

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NATURAL FAMILY PLANNING Periodic Abst Abstinence inence aka Fertility Awareness Method Avoidance of coitus at the time ovum can be fertilized. Couple should determine the day when to woman is fertile. Highly motivated couple Four methods: ✓ Calendar/Rhythm ✓ Cervical mucus ✓ Temperature ✓ Sympotothermal

Calendar Rhythm Method • Oldest periodic abstinence method • Fertile period based on length of cycles o Luteal phase is relatively constant o Follicular phase varies  Ask the patient what is her longest and shortest menstrual cycle. Instruct the patient to record her menses for at least 2-3 cycles. • Fertile period = Shortest cycle min minus us 18 and Lo Longest ngest cycle minus 11 • Couple abstains during the estimated fertile period  Sample Case: If shortest cycle is 27 and longest cycle is 32, what is the woman’s fertile period? ➢ 27 – 18 = 9 ➢ 31-11 = 20 ❖ Fertile period is from days 9 to 20 and couple should abstain or use barriers at this time Basal Body Temperature M Method ethod • Daily monitoring of temperature • Coitus not done or a barrier is used from onset of menses until 3rd consecutive day of elevated temperature • No longer used alone

Cervical Mucu Mucus s / Billing’s Method • Recognition of changes in cervical mucus consistency • Increasing estradiol levels increase the production of cervical mucus • Slippery = potentially fertile. Abstain or use barrier.

• Abstain or use barrier during the menses, and then e very oth other er day after the menses end until th the e first day of that copious slippery mucus is observed to be present. Then the couple abstains daily until 4 days aft after er the last day when the characteristic mucus was present. Symptothermal M Method ethod • Combination of the three methods o Calendar + Cervical mucus: to establish first day of fertile period o Temperature method: to establish last day of fertile period

• Notice ovulation symptoms symptoms.. The "sympto" part of the STM requires that a woman take note of other physical symptoms of ovulation, such as increased cervical and vaginal mucus production, abdominal cramping, breast sensitivity and mood swings. Monitoring mucus quality and quantity is a particularly reliable sign of ovulation. • Take your temp temperature erature every mornin morning. g. The "thermal" part of the STM requires that a woman take her core body temperature each morning before getting out of bed. Use a basal thermometer (an especially sensitive thermometer that has a limited range) to get a reading and then record it on a calendar. Enzyme Immunoassay • Can detect: o Urinary estrogen o Pregnandiol glucoronide (salivary) • Now available in kits, but are quite expensive but not as cumbersome to follow as the traditional symptothermal • Uses dipstick or color indicators

• Increasing levels of progesterone occurring after ovulation cause a detectible rise in daily basal body temperature. • The woman must abstain from intercourse from the cessation of menses unt until il t he third consecutive day of elevated basal temperature, or when she is postovulatory.  Client Instructions for BBT Method Thermal Shift Rule: • Take temperature at about the same time each monitoring (before rising) and record temperature on chart provided by NFP instructor. • Use temperatures recorded on chart for first 10 days of menstrual cycle to identify highest of “normal, low” temperatures (i.e., daily temperatures charted in typical pattern without any unusual conditions) • Disregard any temperatures that are abnormally high due to fever or other disruptions. • Draw a line 0.05-0.1°C above highest of these 10 temperatures. This line is called the cover line o orr temp temperature erature line.

 Periodic Abst Abstinence inence • Women with irregular cycles should not use periodic abstinence methods, over the age of 35, or immediately following a pregnancy. Advantages Di Disadvantages sadvantages ✓ Safe, reversible,  Require highly motivated couple affordable  Higher failure and discontinuation ✓ No pharmacologic rates side effects  Long period of abstinence  Regular cycles (calendar)

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REVERSIBLE METHODS Oral Cont Contraceptive raceptive Pills (OCP) Most common hormonal contraceptives Most widely used reversible method Types of formulation: o Estrogen + Progestin (Combined OCP) o Progestin only (minipill) Currently available in the market: low dose formulations to reduce adverse effects

• The high doses of steroids in the original pill formulations caused minor side effects such as nausea, breast tenderness, and weight gain that frequently led to discontinuation of use.

Sources: Dr. J. Ona Cruz’s 2021 lecture, Comprehensive Gynecology 7th Edition Chapter 13, PARBS |

• Reduction in ethinyl estradiol (EE) dose has coincided with a lower incidence of severe adverse cardiovascular effects and minor adverse symptoms without increasing the failure rate. 3 Types of OCP Formu Formulations lations lations:: ➢ Fixed-Dose Combinatio Combination n • E + P per tablet • 21 active pills - contain same amount of estrogen and progestin • 7 inert or pill-free days (Withdrawal bleeding) o Inert pills do not contain any sex steroid = no contraceptive effect o From the book: Most products are packaged with inactive spacer (placebo) pills during the HFI to improve compliance. Some formulations provide an iron supplement in the spacer pills.  Active pills continuously for 21 days (3 weeks) followed by a 7-day hormone-free interval (HFI). o From the book: Uterine bleeding occurs secondary to hormone withdrawal during the HFI, typically 1 to 3 days after taking the last active pill. This withdrawal bleeding usually lasts 3 to 4 days and is generally lighter than during menses in an ovulatory cycle. ➢ Combination phasic (mult (multiphasic, iphasic, biphasic, triphasic) • 2-3 different dose of E+P represented by different colors of the tablets • Tablets of same dose given for 5-11 days in the 21 medication period • Objective: to simulate fluctuations of sex steroids just like in normal menstrual cycle, in the hope that this will reduce adverse effects; however, this was not exhibited = no advantage • No advantage over fixed dose ➢ Daily Progest Progestin in / Minipill • Low dose progestin • Taken daily at the same time • No steroid free interval • Ideal for nursing mothers o additional protection to lactation amenorrhea o combined OCPs cannot be used because estrogen can inhibit milk production Estrogen in the OCP Progestin in the OCP

• Ethinyl estradiol • Mestranol • Levonorgestrel and derivatives (norgestimate, desogestrel, gestodine) • Norethindrone, norethindrone acetate, norethynodiol, ethinodiol diacetate  Newer ones: Drospirenone, Cyproterone acetate

OCP Generations 1st Generation • OCP formulations contained high amounts of estrogen and progesterone • A lot of women developed cardiovascular complications, or progressed to hypertension o  estrogen = more thrombotic • These were withdrawn from the market 2nd Generation • Pills were reformulated. • Ceiling dose of estrogen content: 50 ug 3rd Generation • Further reduction to 25 ug • Key feature: dose and type of progestin were also modifed • 4th generations would be utilizing the new progestins

OCP: Mechanism o off Action • Inhibition of midcycle gonadotropin surge and prevention of ovulation (more consistent for combined than minipill) Estrogen • From the book: The major effects of the estrogen are to maintain the endometrium and thus prevent unscheduled bleeding as well as to inhibit follicular development through a synergistic effect with the progestin. • Can also inhibit midcycle gonadotropin surge, but to a lesser extent • Causes changes: o thick, viscid, scanty cervical mucus that would impaired transport of ovum and sperm; o can alter or thin out endometrium making it less favorable for nidation o can slow down ciliary moevement of lining Progestin epithelium of the fallopian tube • According to old literatures, failure of contraceptive effects of progestin may cause an ectopic pregnancy because of slowed ciliary action • From the book: The major effect of the progestin component is to inhibit ovulation, but progestins also contribute other contraceptive actions such as thickening of the cervical mucus and thinning of the endometrium.

• Contraceptive steroids prevent ovulation mainly by interfering with release of GnRH from the hypothalamus. • Most studies also support that contraceptive steroids directly suppress the pituitary in addition. • The balance between estrogen and progestin influences the bleeding profile of a combination OC. o Estrogen induces endometrial proliferation. o Progestins oppose the mitotic action of estrogen, leading to a stable decidualized endometrium. • Withdrawal bleeding: bleeding that users of combined OCs experience during the hormone-free interval • Breakthrough bleeding: bleeding that occurs during the time that active pills are ingested • Unscheduled (breakthrough) bleeding and absence of withdrawal bleeding (amenorrhea) occur as a result of insufficient estrogen to support the endometrium. o Increasing the amount of estrogen in the pill formulation or changing progestins often provides a solution

OCP: Adverse Effects • Estrogen component component: o nausea, breast tenderness, fluid retention o minor changes in levels of some vitamins o melasma o mood changes and depression o irregular bleeding esp during the first few months of use o headaches, ↑ frequency of migraines • Progestin component: o androgenic effects (weight gain, acne, nervousness) o adverse mood changes, tiredness o failure of withdrawal bleeding o irregular bleeding Metabolic o headaches • Protein Metabolism Effects: o ↑ hepatic globulin production (estrogen) o factors V, VIII, X, fibrinogen → thrombosis o angiotensinogen → BP elevation o Sex hormone binding globulin (SHBG) reduced by androgens, including androgenic progestins • Carbohydrates Metabolism Effects: o Related to dose, potency, structure and type of progestin o Higher dose potencies and dose → greater impairment of glucose metabolism

Sources: Dr. J. Ona Cruz’s 2021 lecture, Comprehensive Gynecology 7th Edition Chapter 13, PARBS |

Cardiovascular

Reproductive

Neoplastic (highly controversial)

o Gonanes (LNG and derivatives) > Estran Estranes es (Norethindrone and derivatives) • Lipid Metabolism Effects: o Estrogen: ▪ Increase: HDL, total cholesterol, TGs ▪ Decrease: LDL o Progestin: ▪ Increase: LDL ▪ Decrease: HDL, total cholesterol, TGs  Newer derivatives of LNG – less androgenic, more lipid friendly • Coagulation Paramet Parameter er Effects: o Estrogen increases some coagulation factors (e.g. fibrinogen) → enhances thrombosis o Dose dependent • Venous thromboembolism o risk is greater for higher doses (>50 μg) of estrogen • Myocardial infarction o no evidence of increased risk of MI from atherosclerosis • Stroke o conflicting results o no increased risk for past users compared to never users • No permanent infertility • HPO suppression is temporary and reversible • Length of delay of return to fertility related to estrogen dose and user age not duration of use o Postpill amenorrhea is not beyond 6 months • Pregnancy immediately after discontinuation not associated with higher abortion or anomaly rates • Breast cancer o no significantly higher risk compared to never users • Cervical cancer o uncertain, conflicting evidences • Liver adenoma o high dose mestranol formulations (no longer available in the market)

OCP: Cont Contraindications raindications

Absolute Contraindicat Contraindications ions

Relative Contraindicat Contraindications ions

o History of vascular disease (e.g. stroke) o Systemic diseases affecting vascular system o Smokers older than 35 - independent risk factor for cardiovascular complications o Uncontrolled hypertension o Existing breast and endometrial c...