Family Planning:

Overview
Introduction to RH and FP
FP is widely provided under four main reasons:

Socioeconomic or demographic concern;

Health considerations;
Human right arguments; and
Justice and equity reasons.
Types of Contraception
Hormonal contraception

Non-hormonal contraception
Hormonal contraception
Combined hormonal contraception (E+P):
Combined pill (the pill, COC),
Combined injectable,
Combined ring and patch
Progestogen-only contraception (P only):
- Progestogen-only pill (POP)
- Progestogen-only Injectables (PIC)
- Implants
Emergency hormonal contraception
Non-hormonal contraception
Intra-uterine devices
+ progestogen-medicated

Barrier methods

Natural regulation of fertility

Lactation amenorrhoea method (LAM)
Standard Day Method etc

Sterilization: male and female

WHO Eligibility Criteria for Contraceptive Use
Category Description When clinical When clinical
judgment is available judgment is
limited

No restriction for Use the method under

1
use any circumstances
Use the
Benefits generally Generally use the method
2
outweigh risks method

Use of method not

usually recommended,
3
Risks generally unless other methods
outweigh benefits are not available/ Do not use the
acceptable method
Unacceptable
4 Method not to be used
health risk
STI/HIV/AIDS can affect IUD Eligibility

Category
Condition
Initiation Continuation
Current STI, PID or
purulent cervicitis 4 2

High individual risk of

STI 3 2

AIDS
3 2

AIDS and clinically

well on ARV 2 2

HIV positive
2 2

Increased risk of STI

2 2
 Hormonal Contraception:
Mechanisms of Action
Suppress ovulation

Reduce sperm transport

in upper genital tract
(fallopian tubes)

Change endometrium
making implantation less
likely

Thicken cervical mucus

(preventing sperm
penetration)
Combined oral
contraception (COC)
1950s - first COC - trials in Puerto Rico: ENOVID -
mestranol and norethynodel

1969 - first cardiovascular problems reported

Oestrogen + Progestogen
Mestranol Norethynodel

Ethinylestradiol Norethisterone
Norgestrel
Gestodene
Desogestrel
Norgestimate
Drospirenone
Low dose OCP
EE < 50 ug (Usu. 30 or 35)
Progestines dose vary widely b/c differ in
potency by wt.
NE family = 0.4 - 2 mg
Potent prog. = 0.05 0.15 mg
Potency progestational ES, Anti-ES &
Andro.
Types of COCs
Monophasic: All 21 active pills contain same
amount of Estrogen/Progestin (E/P)
Biphasic: 21 active pills contain 2 different
E/P combinations (e.g. 10/11)
Triphasic: 21 active pills contain 3 d/t E/P
combinations (e.g. 6/5/10)
 Pill Free Interval

Designed to induce withdrawal bleeding

Allows follicular growth

Prolonged PFI allows ovulation

Reduced to 4 days with pills < 20 mg

estrogen
 COC: Indications and benefits
High protection against pregnancy
Endometrial and ovarian cancer
Protects for >15 years after discontinuation
Symptomatic PID
Ovarian cysts
Iron-deficiency anemia
Menstrual cramps/ painful periods/ Ovulation pain/
PMS
Heavy or irregular menstrual bleeding
Acne, excess hair on face or body
Symptoms of endometriosis: pelvic pain, irregular
bleeding
 Non contraceptive benefits
1. Fertility related
a. pregnancy effectively
b. Prevent ectopic
2. Menstrual benefits
3. Protection from some cancers
4. Other health benefits
a. Prevent osteoporosis
b. benign ovarian cysts
c. risk of colorectal ca. 25
WHO Medical Eligibility Criteria of contraception (WHO 2004):

COC: Major Risks (WHO 3/4):

Cardiovascular disease: thromboembolism
Multiple risk factors such as smoking, old age, diabetes,
hypertension
Hypertension (in pregnancy is 2)
Deep vein thrombosis
Major surgery with prolonged immobilization
Ischemic heart disease
Stroke
Valvular heart diseases with pulmonary hypertension,
atrial fibrillation risk, Subacute Bacterial Endocarditis
Migraine with aura at any age
Diabetes with vascular involvement or of 20 or more
years duration
 COC: Major Risks (WHO 3/4): Cont.

Breast cancer risk:

No difference among user 10 years before & never users
Slightly increased in current & within past 10 years users
Current or former COC users are less advanced than other womens
Earlier detection among COC users or biologic effect of COC?
Cervical cancer:
Use of COC for 5 years or more fastens development of persistent HPV
infection into cervical cancer
Cervical screening as for other women: Every 3 years (or national guideline)
Gallbladder diseases:
Under treatment or current
Previous History with COC
Liver diseases.
Adenoma or hepatoma
Cirrhosis
CHO & Lipid metabolism
CHO
High dose OCP Glucose Tolerance (GT)
Low dose OCP GT but mild insulin R
Lipid serum level depends on
- EE dose
- Androgenecity of progestins
Estrogen component
serum TGs
HDL,
LDL
28
Women Who Can Use COCs
Without Restriction
Adolescents
Nulliparous women
Postpartum (3 weeks, if not BF)
Immediately post-abortion
Women with varicose veins
Any weight (including obese)
Source : WHO, Medical Eligibility Criteria for Contraceptive Use, 3 rd
Ed. 2004
Women Who Should Not Use COCs
Breastfeeding (<6 weeks postpartum)
Smoke heavily AND are over age 35
At increased risk of CV disease
Have certain pre-existing conditions (e.g.,
breast cancer, liver disease, high risk of CV
disease)
Pregnant (but no proven negative effects on
fetus if taken accidentally)
COC: Side effects
Changes in bleeding:
Lighter, fewer days, irregular, amenorrhea
Headaches
Dizziness
Nausea
Breast tenderness
Weight change
Mood changes
Acne (can improve or worsen, but usually improves)
Other possible physical changes:
Blood pressure: COC induced declines quickly after D/C
COC: Drug interactions

contraceptive potency
Rifampicin
Anticonvulsants: phenytoin, barbiturates etc
HIV drugs
ARV drug interaction?? (WHO 2)
Condom use protects any decrease in
effectiveness of contraception & enhanced
transmission (dual protection)

HIV/AIDS:
Disease transmission and progression??
Missed pill
Missed 1 or 2 pills or started new pack 1 or 2 days late:
Take a hormonal pill as soon as possible.
Little or no risk of pregnancy.
Missed 3 or more pills in 1st/2nd week? Started new pack 3
or more days late?
Take a hormonal pill as soon as possible.
Use a backup method for the next 7 days.
Also, if she had sex in the past 5 days, use ECP
Missed 3 or more pills in the third week?
As above AND
After finish all hormonal pills in the pack start a new pack the next
day without. Using the 7 nonhormonal pills in the old pack
Missed any nonhormonal pills? (last 7 pills in 28-pill pack)
Discard the missed nonhormonal pill(s) continue with the unmissed
Start the new pack as usual.
Extended and Continues Use
Extended use: Skip the last week of pills (without
hormones) in 3 packs in a row.

Continues use no break at all

Patch (Ortho Evra)
Matrix patch releasing 20 g ethinyl
estradiol and 150 g norelgestromin
Parenteral Vs oral delivery of COC;
1 patch/week for 3 weeks followed
by a week off
Pearl index 1.24 per HWY
Side-effects similar to COC
(skin reactions in 20%)
Compliance better than COC
 Combined Vaginal Ring
Ethinyl oestradiol 15
mg/day plus
etonorgestrel 120
mg/day
Three weeks in, one
week out
Effectiveness similar to
COC
Bleeding patterns better
CIC: Types
Cyclofem:
Cyclofem
25 mg depot-medroxyprogesterone acetate and 5
mg estradiol cypionate injected

Mesigyna:
Mesigyna
50 mg norethindrone enanthate and 5 mg
estradiol valerate injected

IM every 28 days

Effectiveness similar to COC

Progestogen-only contraception
(POC)
Safe no effect on arterial or
venous disease
Varying delivery systems
Variable cycle control
Erratic bleeding or amenorrhoea
Side effects:
Bloatedness,
Bloatedness
Breast tenderness,
Altered mood, acne
POC: Mechanisms of Action
Suppress ovulation

Decrease tubal motility

Change endometrium

Thicken cervical mucus

Progestogen-only pill (POP)
Very low dose
Efficacy high in lactating women
?less effective in obese women
Extra contraceptive measures required
if pill is more than 3 hours late
Progestin-Only Injectable
Contraceptives (PIC)
Depo-Provera (DMPA): 150 mg of depot-
medroxyprogesterone acetate given every
3 months
DMPA: IM
DMPA-SC:
DMPA-SC 104 mg pre-filled syringe SC
Noristerat (NET-EN): 200 mg of
norethindrone enanthate given every 2
months
Norethisterone enenthate (NET-EN)
Depo-Provera
3 monthly regimens
High dose potent progestogen
method
Very high efficacy <0.5 per HWY
Delay in return of fertility (6-8
months)
Weight gain of 1-2 kg
Theoretical risk of osteoporosis
Implant: types
Norplant (6 capsules, up to 7 years)
years
Jadelle (2 rods, 5 years)
years
Implanon (1 rods, 3 years)
years
Nesterone
Uniplant
Duration of use is affected by weight
of Norplant and Jadelle users
Norplant:
< 70 kg: 7 yrs
70-79 kg: 5 yrs
> 80 kg: 4 yrs
Jadelle:
> 80 kg: 4 yrs
Implanon: Not affected by weight
Emergency Contraception (EC)

Also known as:

Morning-After Pills
Postcoital Contraception
Secondary Contraception

These terms do not convey the correct timing of use nor that these
methods should be used only for emergencies.
Potential indications for use of EC

Unprotected intercourse (consensual or rape)

rape within
the previous 120 hours
Suspected contraceptive failure within the previous
120 hours
breakage, slippage, or leakage of a male condom
dislodgment, breakage, or incorrect use of a diaphragm,
cervical cap, or female condom
expulsion of an intrauterine device
missed oral contraceptive pills
late injection of injectable contraceptive (>2 weeks late for a
progestin-only formulation)
EC may be provided to the women receiving AC as
a back up method
Special groups CSW, adolescents, women with
repeat abortions
 EC: Types
COC: 12 hrs apart 75 to 80% of pxs
prevented
Low-dose (3035 g EE and 150 g

LNG), or
High-dose (50 g EE and 250 g LNG)

Progestin-Only Pills (POP):

750 g LNG Levonorgestrel

(preferred) X2 (89% )
30 g LNG

37.5 g LNG
When inserted with in 5 to 7
75 g norgestrel days after unprotected sexual
intercourse a copper IUD is 99
IUDs: TCu 380A, Multiload 375, Nova T % effective
ECP Mechanism of Action
Clinical studies have shown that ECPs can
inhibit or delay ovulation
Evidence regarding endometrial alterations
equivocal
Not clear that changes observed would inhibit implantation
Biologic plausibility regarding inhibition of
fertilization
Thickening of cervical mucous
Alterations in tubal transport of sperm or egg
Hormonal EC
Taken within 120 hours of
unprotected sex
Two doses Vs one dose
Minimal side effects
Over the counter
Prevents 75-80% of pregnancies
Two Types of ECPs - side effects
Progestin-only Estrogen and Progestin
Side effects Side effects
Nausea (23%) Nausea (50%)
Vomiting (6%) Vomiting (20%)

Dilayehu B.
Prevention of nausea and vomiting

Antiemetics can be given to reduce nausea and

vomiting
They should be given prophylactically with
estrogen-progestin regimens, given the high
incidence of side effects
May be provided as needed with the better
tolerated levonorgestrel regimen.
Metoclopramide (10 mg) one hour before each
estrogen-progestin dose

Dilayehu B.
 If emergency contraceptives are vomited

If LVN is vomited within one hour of

administration & no antiemetic was given, an
antiemetic agent and then repeating the LVN
If COCs are vomited within one hour of ingestion
and an antiemetic was not taken prophylactically,
then an antiemetic can be given and the COC dose
repeated.
Alternatively, levonorgestrel alone can be
administered for EC.
Intra-Uterine Devices
Development of IUDs
First described in early 1900s
Silkworm gut used in 1909
Graefenburg ring 1931 / Ota ring
Lippes loop with thread 1961
Copper bearing devices- Zipper
1970s
Hormone releasing devices 1980s
 Comparison of Copper IUDs

1st Year Failure Recommended

per 100 women Lifespan
TCu 380A 0.3 12 years

Multiload Cu 250 1.2 3 years

Multiload Cu 375 1.4 5 years

TCu 200 2.3 3 years

Nova T 3.3 5 years

Source:: FHI clinical trials, 1985-1989..

Mirena
levonorgestrel releasing intra-uterine system
52 mg levonorgestrel with steady release
of 20 g/day
Highly effective - as good as female
sterilisation (0.09 per HWY)

5 year lifespan

Very low risk of ectopic pregnancy (0.02 per

HWY)
 COPPER (Cu) CONTAINING IUCDs

THERE ARE DIFFERENT TYPES

Cu T 380A (Widely available in Ethiopia)
Multi-load 250
Multi-load 375
Nova T
Cu T 200 & 220
Cu 7, etc
IUD 62
Cu T - 380A

Also called ParaGard

ParaGard
Widely available
Used for 10 yrs
Very effective, 0.8 pregnancy/100 women
year
Coated with Cu bracelets = 33+33+314mm
Polyethylene with barium sulfate for X-ray
IUD 63
Inflammatory Reaction:-
Creates hostile
environment for sperm
motility/transport, is
spermicidal &
Inhibits implantation of
blastocyst
ADVANTAGES OF IUCD
Highly effective and very safe
Does not interfere with intercourse
Easy to use
Long-acting
Easily reversible
Quick return to fertility
No systemic effects
Complications are rare 65
DISADVANTAGES OF IUCD
Some side effects, including cramping and
increased or prolonged bleeding ( for the
first few months)
Rare complications include perforation and
pelvic inflammatory disease
Insertion and removal require trained provider
No STI/HIV protection
IUD 66
 CRUCIAL FACTORS FOR SAFE
IUCD USE
Careful screening and assessment of
STI risk
Provider is competent/proficient in
IUCD insertion and infection
prevention practices
Reliable backup service available
Careful and complete client counseling
Post-partum intrauterine contraceptive
device (PUIUD)

Advantages
Safety
Access to services
Cost effectiveness
Time and service efficiency
Limitations
Same as for interval IUD
Strings wont be felt initially
Expulsion
3 types
Postplacental - immediately following the
delivery of the placenta in a vaginal birth
Intracesarean - immediately following the
removal of the placenta during cesarean
section
Early postpartum not immediately but
within 48hrs. after delivery.
Barrier methods of contraception

Male condoms
Female barriers:
Diaphragms
Cervical cap, vault cap, vimule
Female condoms
Sponge
Spermicides
Coitus interrupts
Condoms
Large range of types, sizes etc

Mostly latex rubber also plastic

Efficacy 3-23 per HWY: user-failure is high

Offer protection against STIs (Dual

protection)
May be used in conjunction with another method
Female barriers
Very small market share
Require careful explanation and
teaching
Efficacy of diaphragm: 4-20 per HWY
Require to be used by very motivated
individuals
Sterilisation
Worldwide: 150 million women
and 50 million men rely on
sterilisation
Permanent:
Permanent reversibility failure
Highly effective
Methods: surgical/Quinacrine
Non-scalpel vasectomy
Natural Family Planning (NFP): Types
Calendar Method
Standard Day Method
Basal Body Temperature (BBT)

Cervical Mucus Method (Billings)

Symptothermal (BBT + cervical mucus)

 NFP: Contraceptive Benefits
Can be used to prevent or achieve
pregnancy

No method-related health risks

No systemic side effects

Inexpensive
 NFP: Mechanism of Action
For contraception:
Avoid intercourse during the fertile phase of
the menstrual cycle when conception is most
likely.

For conception:
Plan intercourse near mid-cycle (usually days
10-15) when conception is most likely.
NFP:Conditions Requiring Precautions

Irregular menses

Persistent vaginal discharge

Breastfeeding
Calendar Method
Length of at least 6 menstrual cycles
Longest cycle -11= last fertile day of
cycle
Shortest cycle 18 = First fertile day
12 days of abstinence
 The Standard Days Method
Identifies days 8-19 of the
cycle as fertile
Is for women with menstrual
cycles between 26 and 32 days
long
Color-coded string of beads to
keep track of cycle and know
when

Fer ti le
1 2 3 4 5 6 7 8 9 10111213 14 1516171819202122 23 242526 272829
Basal Body Temperature Chart

Infertile

Cover Line
LAM: Mechanisms of Action
Frequent intense suckling
disrupts secretion of
gonadotrophin releasing
hormone (GnRH)

Irregular secretion of GnRH

interferes with release of
follicle stimulating hormone
(FSH) and leutinizing hormone
(LH)

Decreased FSH and LH

disrupts follicular
development in the ovary to
suppress ovulation
 LAM: Criteria for use
Women who:
1. Are fully or nearly fully breastfeeding

2. Have not had return of menses

3. Are < 6 months postpartum

WHO recommends supplementation at 6 months. If begun earlier, LAM is

not as effective.
IUD Use and HIV Acquisition
No biologically plausible protection

Hypothesis Foreign body

inflammation cytokines/cells
HIV infection in uninfected women
HIV shedding in infected women
Hormones and HIV
Possible Mechanisms
Vaginal and cervical epithelium (ectopy,
etc.)
Cervical mucus
Menstrual patterns
Vaginal and cervical immunology
Viral (HIV) replication
Acquisition of other STI
HIV & contraception
Method choice is often complicated
Must include issues related to
1. Efficacy
2. Prevention of transmission of HIV / STI
3. Potential drug interaction
Need detail pts.
- Continued risk of transmission
- Continued prevention
Best method choice
- Dual contraception with hormonal agents + condoms
- IUCD
- Spermicidal
85
 Effectiveness
Method FR/100yrs
DMPA 0.3
NET EN 0.4
CIC 0-0.2
COC 3.0
F-sterilization 0.4
Norplant 0.4
TCU 380A 0.8
 OCP and Lactation
1. Exclusive breast feeding
- LAM for 6 wks & start OCP
- Menses returns
- Not fully breast feeding
- After 6/12 PP which ever comes first
2. Non-breast feeding
- 2-3 wks pp
3. Post abortion
87