1. Failure rates

3. Contraceptive use - USA Female sterilization27% OC 26% Male condom20% Male sterilization10% Withdrawal3% Injectable (MPA)3% Diaphragm2% Implants2% IUD1%

4. Natural family planning identification of potentially fertile days + periodic abstinence calendar - assumption: –ovulation on day 14 (± 2) of menstrual cycle –sperm viability 5 days –oocyte viability 24 hours –abstinence days 9-15 (7-17) failures even with regular cycles, does not account for additional factors (stress, illness, travel) does not work well for women with irregular cycles, chronic cervicitis/vaginitis

5. Natural family planning BBT method: daily temperature readings; temperature rise by 0.4 C/F after ovulation Cervical mucus (Billings) method: observation of the cervical secretions: fertile days - increase in secretions that are clear, strechy and slippery Symptothermal method: combination of the fertility indicators (cervical mucus, BBT and/or calendar) Home ovulation detection kits (urinary LH)

6. Lactational amenorrhoea method Baby less than 6 months Amenorrhoea since lochia ceased Fully or nearly fully breastfeeding 2% chance of pregnancy

7. Barrier methods Male condom (latex, polyurethane) Female condom (polyurethane Reality) Diaphragm (6h/6h, not longer than 24h TSS, UTI) Cervical cap (up to 48h, spermicide necessary, Prentif cap) Spermicides (films, gels, foams, suppositories; nonoxynol-9 2-12%- surfactant that destroys cell membrane; protective against STI)

8. IUD With copper (Copper T380): –sterile, inflammatory, hostile endometrial environment –inhibits sperm migration –inhibits fertilization and oocyte transport With LNG (Mirena): as above PLUS –thickens cervical mucus –augments atrophic decidualization of endometrium –? may inhibit ovulation

9. IUD Appropriate selection Contraindications: –acute PID / history of PID –genital bleeding of unknown etiology –known/suspected uterine or cervical malignancy –decreased immunoresistance (leukemia, AIDS) –allergy to copper –distortion of the uterine cavity –multiple sex partners

10. NOT an abortifacient DOES NOT increase the risk of ectopic (actually decreases the risk) DOES NOT increase the risk of PID DOES NOT increase the risk of subsequent infertility DOES NOT increase the risk of cervical and uterine cancer IUD

11. DMPA injections IM injection every 3 months (150mg of DMPA) blocks LH surge and prevents ovulation side-effects: menstrual changes (irregular bleeding, amenorrhoea)

12. Subdermal implants Norplant I : 5 year LNG implant system (six tubes; 85ug of LNG daily, by year 5 30ug) Norplant II (Jadelle) : 3 year 2 rod system Implanon : (single implant with 3- keto-desogestrel, 3 year) side-effects + difficulties with removal

13. 20-50 ug of EE progestin: –desogestrel, norgestimate, gestodene –LNG, Norethisterone (NET, NETA) monophasic : constant dose of E and P biphasic and triphasic : mainly variation of P dose (also E dose possible) used by 30-40% of reproductive age women in Western Europe Combined oral contraceptives COC

14. prevent ovulation by suppression of pituitary LH/FSH secretion additional P effects: –changes in the cervical mucus hindering sperm transport –changes in the endometrium: prevention of implantation –decreased tubal motility : delayed oocyte transport Combined oral contraceptives COC

15. Ovarian cancer: risk reduction by 40-80% Endometrial cancer: risk reduction by 50% Benign breast conditions (  risk) PID (  risk) Ectopic pregnancies (  risk) Functional ovarian cysts (  risk) Menstrual effects: improvement in regularity + anemia + dysmenorrhea Bone density Acne COC - health benefits

16. Breast cancer: small or no increase Cervical neoplasia: increase in cervical adenocarcinoma, does not increase the risk of invasive cervical cancer VTE: 2-3 fold increased risk (0.4 to 1.0 per 10.000 women, but in pregnancy 6 per 10.000) MI: no increase in the risk (only for the smokers > 35 years) stroke: no increase in the risk with low dose COC in nonsmoking women COC - health risks

17. Appropriate selection Contraindications: –thromboembolic disorder (active or past) –coronary artery/ cerebral vascular disease –carcinoma of the breast –carcinoma of the endometrium or other estrogen-dependent neoplasia –active hepatic disease –pregnancy –smoking after 35 years of age COC - contraindications

18. nausea bloating menstrual changes breast tenderness ?? headache ?? weight gain COC - side effects

19. Indications - can not tolerate E or contraindications: –breastfeeding women –postpartum women –older women with CVD –women at increased risk for VTE NET or LNG no delay (even hours not allowed) in administration Progestin only pills (POP)

20. Immediate IUD Yuzpe method: 72h, efficacy max. 24h; 2 pills 250ug LNG + 50ug EE (Ovran) followed by further two tablets 12 hours later LNG alone (POEC): 750ug LNG stat and 750ug LNG 12h later; 72h, efficacy max. 24h; more effective than Yuzpe, fewer side effects (nausea+vomiting) Emergency contraception