1. FAMILY PLANNING & CONTRACEPTION
ASSOCIATE PROFESSOR
IOLANDA ELENA BLIDARU
MD, PhD

2. FAMILY PLANNING Aspects of the problem national social personal ethnic
In no other branch of medicine are social, religious, and political forces more obvious than in family planning.

3. CONTRACEPTION Definition – avoiding an unwanted pregnancy
Elective abortion is not a contraceptive technique.
no contraception + presumably fertile sex partners = about 90 % of women will conceive within 1 year.
While there is no totally safe contraceptive method, and the lack of contraception is even more dangerous, both are less dangerous than driving an automobile for 1 year.

4. CONTRACEPTION Classification of the methods the user – male / female
the duration – temporary (reversible) / permanent (irreversible)
the type: hormonal, mechanical, chemical, natural, surgical, mixed
emergency or routine contraception

5. CONTRACEPTION Effectiveness – Pearl Index
Total no. of accidental pregnancies x 1200 / total months of use = % per 100 women-years of exposure
Failure rates for some methods vary considerably, largely because of the potential for failure caused by imperfect use (user failure) rather than an intrinsic failure of the method itself.

6. The characteristics of the ideal contraceptive method
CONTRACEPTION
The characteristics of the ideal contraceptive method
• highly effective
• no side effects
• cheap / gratis
• independent of intercourse
• rapidly reversible
• widespread availability
• acceptable to all cultures and religions
• easily distributed
• easily administrated (by non - healthcare personnel).

7. Contraceptive counselling
CONTRACEPTION
Contraceptive counselling
the contraceptive choice
the provision of method
the advice on using the method

8. Classification CONTRACEPTION Hormonal contraception
Intrauterine contraception
Copper intrauterine device (IUD)
Hormone-releasing intrauterine system (IUS)
Barrier methods Condoms (male, female)
Female barriers
Natural family planning methods: Periodic abstinence, Coitus interruptus, Lactation
Emergency contraception
Sterilization Female sterilization
Vasectomy

9. CONTRACEPTION Hormonal contraception
Combined oral contraceptive pills (COC)
Combined hormonal patches
Vaginal ring
Progestogen-only preparations
- Progestogen-only pills (POP)
- Injectables
- Subdermal implants

10. Hormonal contraception
Combined hormonal patches – Ortho Evra
Vaginal ring - NuvaRing
etonogestrel + EE

11. Hormonal contraception
Progestogen-only preparations
Progestogen-only pills (POP) – Cerazette
contains desogestrel.
Injectables
- norethindrone enanthate (NET – EN) – 8 weeks
- medroxiprogesteron acetate depot (DMPA) – 12 weeks

12. Hormonal contraception
Subdermal implants
delivery of a steroid progestin from polymer capsules or rods placed under the skin.
Implanon - 4 cm/ 2 mm Implanon rod contains 68 milligrams of etonogestrel which is released over a 3 year period.

13. COMBINED ORAL CONTRACEPTIVE PILL

14. Formulations
Monophasic (each tablet contains a fixed amount of estrogen and progestin);
Biphasic (each tablet contains a fixed amount of estrogen, while the amount of progestin increases in the second half of the cycle);
Triphasic (the amount of estrogen may be fixed or variable, while the amount of progestin increases in 3 equal phases).

15. Estrogens Types of estrogen ethinyl estradiol,
mestranol, a “prodrug” that is converted in vivo to ethinyl estradiol.
estradiol, ex: Zoely - acetat de nomegestrol + estradiol
estetrol

16. Progestins can be classified according to their chemical structure as
19-nortestosteron derivatives: norethisteron, linestrenol, etinodiol diacetat şi levonorgestrel;
17 alfa-hidroxiprogesteron derivatives: medroxiprogesteron acetat, clormadinon acetat, cyproteron acetate;
progestines of the new generation: desogestrel, gestodene, dienogest, norgestimate
spironoloctone derivatives - drospirenone

17. EFFICACY
The combined OC = a highly effective method of reversible contraception.
With perfect use, the combined OC is 99.9% effective in preventing pregnancy.
However, typical use = failure rates range from 3 - 8%.

18. MECHANISM OF ACTION
Main mechanism of action is to suppress gonadotropin secretion, thereby inhibiting ovulation.

19. Additional mechanisms of action
MECHANISM OF ACTION
Additional mechanisms of action
endometrial atrophy, making the endometrium unreceptive to implantation;
Increased viscousity of the cervical mucus - impedes sperm transport;
effect on fluid secretion and peristalsis within the fallopian tube, which interferes with ovum and sperm transport.

20. INDICATIONS
In the absence of contraindications, use of the combined OC may be considered for any woman seeking a reliable, reversible, coitally-independent method of contraception.

21. CONTRAINDICATIONS
The World Health Organization (WHO) has developed a list of absolute and relative contraindications to the use of combined OCs, based on the available evidence of risks

22. ABSOLUTE CONTRAINDICATIONS
< 6 weeks postpartum if breastfeeding
Smoker over the age of 35 (≥ 15 cigarettes per day)
Hypertension (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg)
Current or past history of venous thromboembolism (VTE)
Ischemic heart disease
History of cerebrovascular accident
Complicated valvular heart disease
Migraine headache with focal neurological symptoms
Breast cancer (current)
Diabetes with retinopathy / nephropathy / neuropathy
Severe cirrhosis
Liver tumour (adenoma or hepatoma)

23. RELATIVE CONTRAINDICATIONS
Smoker over the age of 35 (< 15 cigarettes per day)
Adequately controlled hypertension
Hypertension (systolic 140–159mm Hg, diastolic 90–99mm Hg)
Migraine headache over the age of 35
Currently symptomatic gallbladder disease
Mild cirrhosis
History of combined OC-related cholestasis
Users of medications that may interfere with combined OC metabolism

24. These side-effects may lead to discontinuation of the combined OC.
Some combined OC users will experience minor side-effects, most commonly during the first 3 cycles.
These side-effects may lead to discontinuation of the combined OC.

25. The most common reason patients discontinue combined OC use
SIDE-EFFECTS
The most common reason patients discontinue combined OC use
Abnormal menstrual bleeding,
Nausea,
Weight gain,
Mood changes,
Breast tenderness,
Headache.

26. WEIGHT GAIN
Placebo-controlled trials have failed to show any association between low-dose combined COC and weight gain.
Studies comparing the COC to other contraceptive methods have failed to show a significant associated weight gain.

27. BREAST CANCER
The risk of breast cancer in combined OC users is still controversial.
The research suggested that there was a small but significant increase in risk of breast cancer in women who are smokers and currently taking the combined OC and in the first 10 years after discontinuing it.

28. CERVICAL CANCER
Long-term COC use may increase the risk of cervical cancer in women who are HPV positive but not in women who are HPV negative.
Infection with HPV,as the major risk factor for cervical cancer, is related to sexual behaviour.

29. NON-CONTRACEPTIVE BENEFITS
Decreased endometrial cancer
Decreased ovarian cancer
Decreased risk of fibroids, endometriosis
Cycle regulation
Decreased menstrual flow
Increased bone mineral density
Decreased dysmenorrhea
Decreased peri-menopausal symptoms
Decreased acne
Decreased hirsutism
Decreased incidence of salpingitis and PID
Possibly fewer ovarian cysts
Possibly fewer cases of benign breast disease
Possibly less colorectal carcinoma

30. 1. PATIENT ASSESSMENT
Before prescribing a COC, a thorough history should be taken, including potential contraindications, smoking history, and medications.
The physical examination should include a blood pressure measurement.

31. No routine laboratory screening is required.
1. PATIENT ASSESSMENT
No routine laboratory screening is required.
2. Counselling

32. (Intra Uterine Device for contraception)
I.U.D.
(Intra Uterine Device for contraception)

33. First generation
I.U.D.is
Lipes loop
Second generation
I.U.D. is
Copper T-200
Third generation
Gyne-T 380
With 8 years
Intra uterine life

34. Levonorgestrel Forth generation I.U.D.
MIRENA
Jaydess
A capsule on the
Stem contain mixture
Of silicon rubber &
60mg of progestin
60mg
Levonorgestrel
Developed by steroid
research Laboratory-Finland
releasing 20mcg per day
estimated to last 5 years.
Forth generation
I.U.D.