1. Dr Ibtesam Ghadanfar Consultant OB&GYN Adan Hospital

2. Introduction It is estimated that contraceptive prevalence among women of reproductive age is 63 % worldwide and 77 % in the United States. Still 3.2 million unintended pregnancies occurred in the USA in 2006.

3. Why Uninteded Pregnancy? Women choose not to use contraception? Pregnancy risk assessment monitoring system interviewed 8000 women who gad a viable pregnancy and did not use birth control: 33% thought they could not get pregnant at the time 30% did not mind if they get pregnant 22% stated their partner did not want to use a method 16% cited side effects 10% thought they or the partner were sterile 10% access problem 18% others

4. Complications of Unintended Pregnancy Significant costs In UK in 2010 the coverage of 218.100 unintended pregnancies was 299,200,00 dollars In USA annul cost is 4.6 billion dollars. In our setup we have to consider several issues: Legal Religious Added costs: Prolonged admission Monitoring Neonatal admission costs / morbidity

5. Factors to consider before recommending a contraceptive method include: ● Efficacy ● Convenience ● Duration of action ● Reversibility and time to return of fertility ● Effect on uterine bleeding ● Type and frequency of side effects and adverse events ● Cost ● Accessibility ● Protection against sexually transmitted diseases ● Non contraceptive benefits ● Medical contraindications

6. Pearl Index The number of failure of contraceptive method per 100 women years of exposure Usually two Pearl Indexes are published from studies of birth control methods: Actual use Pearl Index, which includes all pregnancies in a study and all months (or cycles) of exposure. Perfect use or Method Pearl Index, which includes only pregnancies that resulted from correct and consistent use of the method, and only includes months or cycles in which the method was correctly and consistently used.

8. Effectiveness The effectiveness of a contraceptive method is expressed as both the theoretical (perfect use) efficacy and the actual (typical use) effectiveness In practice, contraceptive methods can be divided into three categories based upon their theoretical and actual effectiveness.

9. Comparing Effectiveness of Contraceptive Methods

10. Types of Contraception Hormonal Combined Estrogen/Progestin: pills, patches, rings Progestin only: pills, vaginal rings, implants, injectable Levonorgestrel IUCD Non Hormonal Cupper IUICD Barrier methods: Condom, diaphragm, sponge and cervical cap Tubal ligation and occlusion Vasectomy Others

11. Complications of Contraception Myocardial infarction: Risk of MI is doubled in healthy non smokers women MI is extremely low in these women to start with. So the attributable risk is very low. Older women, smokers carry a significant risk Hypertension: In a large study (70,000 nurses) the RR was only 1.8 for current users of OCP which reverts on stopping. VET risk is low RR 3.5 which is less than the risk during pregnancy

12. General Rules Permanent non reversible methods are the best: Completed Family. Pregnancy imposes considerable risk on the wellbeing or life of the patient. Tubal occlusion/ligation or vasectomy Women with active cancer or who have been treated for cancer within six months: avoid estrogen-progestin contraceptives due to increase risk of DVT. Women with osteopenia or osteoporosis: avoid injectable progestin-only contraception (eg, DMPA). These women may benefit from the effects of an estrogen-containing contraceptive on bone mineral density. Women who are immunosuppressed: intrauterine contraception is not contraindicated. Women at risk of breast cancer or recurrence: emergency contraceptive pills are not contraindicated. Avoid estrogen containing methods in women with risk factors for DVT.

13. Cardiovascular & Hypertensive diseases Safest method is IUCD weather cupper or levonorgestrel device. Progestin preparation can be used except injectable form (Depot medroxyprogesterone acetate) as it has a negative effect on bone density. Avoid estrogen containing methods due to increased risk of DVT.

14. Diabetes Copper IUCD is the preferred method of use. Hormonal and non hormonal are also acceptable in diabetics with no vascular manifestations. In case of nephropathy, retinopathy, neuropathy and diabetes more than 20 years, hormonal methods are to be avoided.

15. H/O Deep Venous Thrombosis Patients with high risk for DVT (more than one risk factor) or low risk DVT (no risk factor) are advised to avoid estrogen containing methods. Best method is long acting contraceptive weather reversible or permanent method. Copper IUCD is preferred. Progestin only methods are acceptable as the benefits out way the theoretical risks.

16. Known Thrombogenic Mutations Such as: Factor V Leiden Prothrombin mutation Protein S, protein C, and antithrombin deficiencies Best method is copper IUCD followed by the progestin only methods. Avoid estrogen containing methods.

17. Systemic Lupus Erythematosus Levonorgestrel IUCD is a safe and effective option: It has not been shown to increase thrombosis risk. No detectable impact on bone density. Reduction in menstrual blood loss which is particularly helpful for patients on anticoagulation Combined estrogen-progestin contraceptives are better avoided. However, they may be used in patients with stable low disease activity and documented negative antiphospholipid antibodies.

18. SLE & Contraception Progestin-only contraceptives such as the progestin- only pill are a good option for SLE patients who do not want to use an IUCD and have high disease activity, a positive aPL, or other contraindications to the use of estrogen. Depomedroxyprogesterone acetate (DMPA) is not a good long-term option for SLE patients with osteoporosis or long-term glucocorticoids use due to risk of decreased bone density.

19. Neurological Conditions Non migraine headaches: All methods are safe for use Migraine headaches: Copper IUCD is the best option. Epilepsy: Patient not on any drugs can use any method depending on their preference and other factors. Patient on treatment such as (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) are advised to use IUCD due to drug interaction

20. Breast Cancer Patients with current breast cancer or H/O breast cancer: Sterilization when indicated. Best is copper IUCD. However, a levonorgestrel- releasing IUD is recommended to reduce the risk of tamoxifen-induced endometrial changes without increasing the risk of breast cancer recurrence. Avoid all hormonal methods.

21. Inflammatory Bowel Disease Safe methods are IUCD (copper and hormonal types) and progestin implants. They should avoid COP, POP and depot medroxyprogesterone acetate.

22. Anemia Thalassemia Sickle cell Iron deficiency Avoid copper IUCD due to the potential for menorrhagia. All other hormonal methods are good including levonorgestrel IUCD.

23. Conditions in which a progestin-only contraceptive may be desirable Migraine headaches Age over 35 years and smoker or obese History of thromboembolic disease Cardiac disease, especially coronary artery disease or heart failure Cerebrovascular disease Early postpartum period Hypertension with vascular disease or older than 35 years of age Systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies Hypertriglyceridemia

24. Women with Disabilities Women with limited mobility, such as those in wheel chairs: Negative effect of DMPA and immobility itself on bone mineral density. Increased risk of thrombosis associated with estrogen-progestin contraceptives. A levonorgestrel-releasing intrauterine device (IUD) significantly reduces menstrual bleeding and requires little to no attention while not carrying either of these risks appears to be a good option. The progestin implant contains no estrogen and requires no attention, but is less likely to result in amenorrhea than the IUD. The IUD can be left in place for five years and the implant for three years. Progestin-only pills are an alternative, but must be taken daily, have a higher failure rate, and provoke irregular bleeding.

25. When is it safe to stop using hormonal contraception? Contraception remains important during perimenopause, as women cannot be certain of infertility until they reach menopause. Determining when hormonal contraception can be safely discontinued is challenging. One approach in healthy nonsmoking women is to discontinue hormonal contraception when the risk of pregnancy is clearly remote based on age: ACOG and the North American Menopause Society (NAMS) put this age between 50 and 55 years. She can switch to a non hormonal contraceptive. If over time she can be diagnosed as menopausal, then the non hormonal contraceptive can be discontinued, as well.

26. CDC Medical Eligibility Criteria for Contraceptive Use

27. Thank you