Medical Archive

Introduction

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Efficacy

Safety

Medical Eligibility for Contraception

Status	Contraindications	Alternative
Active liver disease (cirrhosis & liver cancer) Active breast cancer Ovarian cancer	<All hormonal methods> OCS, contraceptive patch, vaginal ring Progetin IUD	Copper IUD
Endometrial cancer Cervical cancer Gestational trophoblastic disease Distorted endometrial cavity Acute PID history <3 months Wilson disease Copper allergy Pregnancy	Copper IUD	OCS
Unexpected vaginal bleeding	Copper IUD Hormonal contraception	Further evaluation
Migraine with aura >15 cigarettes/day + age >35 Hypertension >160/100mmHg	Hormonal contraception	Progestin-only preparations
<Thrombotic diathesis> History of thromboembolic disease Antiphospholipid-antibody syndrome History of stroke Major surgery with prolonged immobilization	Hormonal contraception
Heart disease DM with end-organ damage Use <3 weeks postpartum	Hormonal contraception

• Adolescents
  • Long-acting, reversible contraceptive devices (LARCs) such as IUDs and subdermal progetin implant are first-line contraception options d/t lowest failure rate and highest effectiveness
  • OCs and hormonal patches/vaginal rings have a lower efficacy than LARCs.
  • DMPA is not recommended.

Cost

Long-Acting Reversible Contraceptives

Nonhormonal Methods

Spermicide, diaphragms are related to increased risk of UTI

Coitus Interruptus

Breastfeeding

Fertility Awareness

Condoms

STD ?, ?? ??? ?, but Latex allergy
Vaginal diaphragm, cervical cap? TSS risk ??

Vaginal Spermicides

Coitus 30? ? ??, 6?? ?? douching X
??? ???? controversial

Vaginal Barriers

Intrauterine Contraception

Copper IUD	~10?	inflammation? ?? ?? ?	???
LNG-IUS (mirena)	5?	??? ?? ???	??? (P ????)

• Advantage
  • No effect on hypertension (cf. hormonal contraception)
  • High efficacy (>99%)
  • No effect on future fertility
    • Can be removed at any time the patient desires pregnancy, with immediate return of fertility.
• Disadvantage
  • Not recommended for patients with dysmenorrhea as its inflammatory reaction in the uterus may increase pain symptoms.

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Cx: ??, ?? HIV, Actinomyces infection ? ?? ??!

?????? Tail? ?? ?? ??. ?? ???? USG-guided IUD removal
USG?? fundus? ??? ??? ???? IUD ? ?? ???? ??.

Hormonal Contraception

Steroid Hormone Action

Progestins

?? ???? progestin? ?? ??? ????.
??, ??? ?? systemic effect? ????, local effect? ????.
Systemic effect
? Systemically active progestin (??????? ??)
? Suppressing GnRH in the hypothalamus
Local effect
? Progestin-containing contraceptives (???)
? Thin the uterine lining, which may theoretically impair embryo implantation.

Estrogens

• Effective for dysmenorrhea treatment and contraception as estrogen inhibit ovulation.

Antifertility Effects

Combination Estrogen–Progestin Contraceptives

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  • MCD #7 ?? ??. 3?? ???? 1?? ??, ? 1??? ??? ??
  • ?? ???<12hr: ?? 1? ??, ???? 1?
  • ?? ???>12hr: ?? ? 2? ?? + ?? ?? ?? ? ??
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  • s/e ??, ?? ??? ???, ??? ?? ??

Progestin-Only Preparations

LH surge ?? (FSH? x)?, ???? ?? ???, ?? ??
-> Cycle? ???? IUD?? sperm? ???? ??? ??.
-> ???? ?? ?? ??? ??!
?? ???, ?? Progestin

Transdermal Hormonal Contraception

Hormonal Implants

Ef?cacy of Hormonal Contraception

Metabolic Effects and Safety

• Hypertension
  • Worsen preexisting hypertension d/t estrogen-induced hepatic angiotensinogen synthesis.
  • Cause a mild elevation in BP and sometimes (~5% of chronic users) can lead to overt hypertension.
  • The risk increases with the duration of OC use.
  • Discontinulation can reduce BP and often corrects the condition.

• Absolute contraindication
  • History of thromboembolic event
  • History of estrogen-dependent tumor
  • ??? ???, ??? ??
  • ?? ?? ???
  • ?? ??? High TG (IUD ???)
  • ?? ??? severe hypertension ? P only
  • 35? ??? ?? ???
• Relative contraindication
  • Mild or medication-controlled hypertension ? P only

??? 6??? ???? risk ????? ?? ?? -> P ?????

Health Bene?ts of Oral Contraceptives

• Endometrial & ovarian cancer risk reduction
  • Cf) slightly increased risk for cervical and breast cancer, which returns to normal within 10 years of OCP discontinuance.
• Menstrual regulation (eg, anovulation, dysmenorrhea, anemia)
• Hypeprandrogenism treatment (eg, hirsutism, acne)

Fertility after Oral Contraceptive Use

Sexuality

Teratogenicity

Interaction of Oral Contraceptives with Other Drugs

Oral Contraceptives and Clinical Chemistry Alterations

Choice of Oral Contraceptives

Alternative Routes for Hormonal Contraception

Patch and Ring and Thrombosis

Injectable Hormonal Contraceptives

Depomedroxyprogesterone acetate (DMPA, depot MP)

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  • OCS? ?? ??.
  • Administered IM every 3 months.
  • Inhibit pregnancy by release of GnRH from the hypothalamus and suppressing ovulation.
• ??
  • ?? ?? ??? action duration? ??. IDA???? ???
• Complications
  • Menstrual irregularities
    • Especially during the first 6 months of use
    • ~50% have amenorrhea after 1 year of use
  • Endocrinal effects
    • ?Body fat, ?lean muscle mass, cause weight gain
    • ??? ?? ??? ??? (E ?????) – ???/?? ???? ???? ??.

Subcutaneous DMPA

Once-a-Month Injectable

Subdermal Implants

• Progestin-releasing subdermal implant
  • Long-acting, reversible contraceptive used for precoital contraception
  • Sustained release of low-dose progestin ? cannot achieve the acute increase in progestin levels required to delay ovulation for EC.
  • Like DMPA, similar side effects of irregular menses and breast tenderness.

Emergency Contraception

Method	Mechanism	Timing after intercourse	Efficacy	Contraindications
Copper-containing IUD		0-120hr	>99%	Acute pelvic infection Severe uterine cavity distortion Wilson disease Complicated organ transplant failure
Ulipristal	PR blocker	0-120hr	98-99%	None
Levonorgestrel	P	0-72hr	59%-94%	None
Oral contraceptives (Multiple pills)	E+P	0-72hr	47-89%	None

OCS: side effects (eg, severe nausea) d/t the high estrogen content.
Dosing: “Now and again in 12 hours”

Antiprogestins

To delay ovulation and impair implantation.

The Copper Intrauterine Device for Emergency Contraception

To prevent impairing implantation.

Hormonal Contraception for Men

Sterilization

Female Sterilization

Surgical Technique

Yoon’s ring > ?? ???(unipolar, ???? ? ??. 49%)

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PID ??
Obesity / DM
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Laparoscopy

Risks of Tubal Sterilization

Sterilization Failure

Hysteroscopy

3?? ? ???

Risks of Hysteroscopy

Sterilization Failure with Hysteroscopic Methods

Reversal of Sterilization

Late Sequelae of Tubal Sterilization

Vasectomy

Reversibility

Safety

Abortion

Safety

Techniques for First-trimester Abortion

Vacuum Curettage

Medical Means for First-Trimester Abortion

Methotrexate/Misoprostol and Misoprostol Alone

Complications of Medical Abortion

Second-Trimester Abortion

Dilation and Evacuation

Labor-Induction Methods

Combination of Induction and Assisted Delivery

High-Dose Oxytocin

Complications of Second Trimester Abortion

Surgical Abortion Complications

Induction Abortion Complications

Selective Fetal Reduction

The Future

Spermicides

Intrauterine Devices

Vaginal Rings

Barrier Methods

Contraceptive Vaccines

Male Contraception

Simple Means for Female Sterilization