Contraceptives

Dr Madhu Gupta, MD
Additional Professor of Community Medicine
Department of Community Medicine and School of Pubic Health
Post Graduate Institute of Medical Education and Research
Chandigarh
 Outline
• Objective
• Introduction
• Contraceptive methods
– Spacing Methods
– Permanent Methods
• Take home message

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 Objective
• To learn and understand various
contraceptive methods, their usage, side
effects and effectiveness

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 Introduction
• Contraception refers to methods used to
prevent pregnancy
• Planning, provision and use of birth control is
family planning
• Choice of contraceptive method depend upon
the NEED of the users
• None of the methods is completely effective
• Failure rates for most reversible methods are
strongly influenced by compliance

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 Types of Contraceptive Methods

Contraceptive
Methods

Temporary Methods Permanent Methods

Hormonal Non Hormonal Pill Barrier/Mechanical Methods based on Male and Female sterilization
Methods information

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 Temporary/Spacing
Methods

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 Hormonal Methods
 Oral Contraceptives Pills (OCPs)
 Injections (Depo-Provera)
 Implants (Norplant I& II)
 Vaginal Ring
 Skin Patch
 Oral Contraceptive Pills
(OCPs)

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 Combined pill: Mala D
Most commonly used method
Available in Government supply
Contains two hormones:
Estrogen and Progesterone which prevent an
egg from being released from a woman's
ovary each month
Effectiveness: 99% if taken correctly
How does the pill work?
Stops ovulation
Thins uterine lining
Thickens cervical mucus
 Oral Contraceptive Pills
Pills are safe and effective when taken
properly to prevent pregnancy

A full medical history is essential before

prescribing

Women must have a pap smear to get a

prescription for birth control pills
Not suitable for women with:
– high blood pressure
– circulatory disease
– diabetes
– women over 35years
– who smoke
– who are overweight

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 Taking the Pill
• Start from the fifth day of mensis
• Once a day at the same time everyday
• Use condoms for first month
• Use condoms when on antibiotics
• Use condoms for 1 week if you miss a pill or take one late
• The pill offers no protection from STD’s

The combined pill is not reliable if taken over 12 hours late or if

have vomiting and diarrhea, when extra protection is required

Some drugs like antibiotics can also affect its reliability

 Progesterone-only pill (mini pill)

• Unlike the combined pill, this only contains

the hormone Progesterone.
• This type of pill is good for women who are
breast-feeding, older women, smokers and
others who cannot use the combined pill.
• Effectiveness: 98% if taken correctly.
 Benefits of OCPs
Prevents pregnancy
Eases menstural cramps
Shortens period
Regulates period
Decreases incidence of ovarian cysts
Prevents ovarian and uterine cancer
Decreases acne
The pill does not interfere with the spontaneity of
sex
reduce pre-menstrual syndrome (PMS) and period
pain
 Side-effects

Breast tenderness
Nausea
Increase in headaches
Moodiness
Weight change
Spotting
 Injection: Depo-Provera
• Birth control shot given once every
three months to prevent pregnancy
• 99.7% effective preventing pregnancy
• No daily pills to remember
How does the shot work?
• Stops ovulation
• Stops menstrual cycles
• Thickens cervical mucus
 Side effects
Extremely irregular menstrual bleeding and
spotting for 3-6 months!
NO PERIOD  after 3-6 months
Weight change
Breast tenderness
Mood change

*NOT EVERY WOMAN HAS SIDE-EFFECTS!

 Implants
Implants are placed in the body filled with hormone
that prevents pregnancy
Physically inserted in simple 15 minute outpatient
procedure
Plastic capsules the size of paper matchsticks
inserted under the skin in the arm
99.9% effectiveness rate
 Norplant I vs Norplant II

• Six capsules • Two capsules

• Five years • Three years
Norplant Implant
 Norplant Considerations
• Should be considered long term birth
control
• Requires no upkeep 
• Extremely effective in pregnancy
prevention > 99%
 Emergency Contraception
Emergency contraception pills can reduce
the chance of a pregnancy by 75% if taken
within 72 hours of unprotected sex!
 Emergency Contraceptive
Pill (ECP)

• Must be taken within 72 hours of the act of

unprotected intercourse or failure of
contraception method
• Must receive ECP from a physician
• 75 – 84% effective in reducing pregnancy
 ECP
Floods the ovaries with high amount of hormone
and prevents ovulation
Alters the environment of the uterus, making it
disruptive to the egg and sperm
Two sets of pills taken exactly 12 hours apart
 Vaginal Ring (NuvaRing)
• 95-99% Effective
• A new ring is inserted into the vagina each month
• Does not require a "fitting" by a health care provider,
does not require spermicide, can make periods more
regular and less painful, no pill to take daily, ability to
become pregnant returns quickly when use is stopped.

NuvaRing is a flexible
plastic (ethylene-vinyl
acetate copolymer)
ring that releases a
low dose of a
progestin and an
estrogen over 3
weeks.
Skin Patch
 Transdermal Patch
Ortho Evra
– Patch is placed on buttock, abdomen,
outer upper arm, or upper torso
– Replaced weekly for 3 weeks, then a
patch-free week
– Costly ($420 per year)
– Pros: no daily pill; spontaneity
– Cons: no STD protection, skin irritation

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 Non Hormonal Pill

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 Centchroman
• Ormeloxifene
• Non steroidal, non hormonal
• Acts by causing asynchrony in the menstural
cycles between ovulation and uterine lining
• Twice a week for first three month
• Weekly schedule: 30 mg
• Failure rate of 1-2%
• Can cause delayed mensturation

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 Barrier Methods
• Spermicides
• Male Condom
• Female Condom
• Diaphragm
• Cervical Cap
 Barrier Method
• Prevents pregnancy blocks the egg and
sperm from meeting
• Barrier methods have higher failure rates
than hormonal methods due to design and
human error
 Spermicides
• Chemicals kill sperm in the vagina
• Different forms:
-Jelly -Film
-Foam -Suppository
• Some work instantly, others require pre-insertion
• Only 76% effective (used alone), should be used in combination
with another method i.e., condoms
 Male Condom
• Most commonly used method
• Effective barrier method when used properly
• Available in government supply
• Latex and Polyurethane Condoms available
• Prevent pregnancy and spread of STD’s
(including HIV)
 Male Condom

• Effectiveness rate = 88%

• Combining condoms with spermicides
raises effectiveness levels to 99%
 Female Condom
• Made as an alternative to male condoms
• Polyurethane
• Physically inserted in the vagina
• Effectiveness rate = 79%
• Woman can use female condom if partner
refuses
 The Female Condom

The female condom is a lubricated polyurethane sheath,

similar in appearance to a male condom. It is inserted into
the vagina. The closed end covers the cervix. Like the
male condom, it is intended for one-time use and then
discarded.
 Diaphragm
• Typical Effectiveness Rate = 80%
• The diaphragm is a flexible rubber cup that is
filled with spermicide
• Self-inserted over the cervix prior to intercourse.
• Inserted up to 18 hours before intercourse and
can be left in for a total of 24 hours
• It is a prescribed device fitted by a health care
professional and is more expensive than other
barrier methods, such as condoms
Diaphragm
 Cervical Cap
• Latex barrier inserted in vagina before
intercourse
• “Caps” around cervix with suction
• Fill with spermicidal jelly prior to use
• Can be left in body for up to a total of 48 hours
• Must be left in place six hours after sexual
intercourse
• Typical effectiveness rate = 80%
Cervical Cap

The cervical cap is a flexible rubber cup-like device that is filled with
spermicide and self-inserted over the cervix prior to intercourse. The
device is left in place several hours after intercourse. The cap is a
prescribed device fitted by a health care professional and can be more
expensive than other barrier methods, such as condoms.
 Sponge

The sponge is inserted by the woman into the vagina and covers the cervix blocking sperm from
entering the cervix. The sponge also contains a spermicide that kills sperm. It is available without a
prescription
 Intrauterine Devices (IUD/CuT)
• Available in government
supply
• T-shaped object placed in the
uterus to prevent pregnancy
• Must be on period during
insertion
• A natural childbirth required to
use IUD
• Extremely effective without
using hormones > 97 %
• Must be in monogamous
relationship
 The intrauterine device (IUD) shown uses copper
as the active contraceptive, others use
progesterone (Merina) in a plastic device.
IUDs are very effective at preventing pregnancy
(less than 2% chance per year for the
progesterone IUD, less than 1% chance per year
for the copper IUD).
IUDs come with increased risk of ectopic
pregnancy and perforation of the uterus and do not
protect against sexually transmitted disease.
IUDs are prescribed and placed by health care
providers.
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 Copper T vs.. Progestasert
• 10 years
• 99.2 % effective
• Copper on IUD acts as
spermicide, IUD blocks
egg from implanting
• Must check string before
sex and after shedding of
uterine lining.
• 1 year
• 98% effective
• T shaped plastic that
releases hormones over
a one year time frame
• Thickens mucus, blocking
egg
• Check string before sex &
after shedding of uterine
lining.
 Methods based on
information

• Withdrawal method
• Natural Family Planning
• Fertility Awareness Method
• Abstinence
 Withdrawal
(Coitus Interruptus)
• Removal of penis from the vagina before
ejaculation occurs
• NOT a sufficient method of birth control by
itself
• Effectiveness rate is 80% (very
unpredictable in teens, wide variation)
• 1 of 5 women practicing withdrawal
become pregnant
• Very difficult for a male to ‘control’
 Natural Family planning
methods
 Calendar (Rhythm) method
 Basal body temperature
 Cervical mucous method
 Ovulation awareness method
 Lactational amenorrhea method
 Basal Body Temperature Method
• BBT=body temp in resting state on waking
• Slight drop immediately before ovulation
• After ovulation, release of progesterone
causes slight increase in temperature
 Standard Days Method (w/Cyclebeads)
If you have not started 1 On the day you start your
your period by the day your period, move the
after you put the ring on ring to the RED bead.
the last brown bread,
contact your provider. Also, mark this date
on your calendar

2 Every morning
If you start
your period move the ring
before you put to the next
the ring on the bead.
darker brown Always move
bead, contact the ring from
your provider. On WHITE bead days the narrow to
(may not be a good you can get pregnant. the wide end.
method for you)
Avoid unprotected
intercourse to prevent
On BROWN bead a pregnancy.
days you can
have intercourse
with very low When you start your
probability of next period, move the
pregnancy. ring directly to red
bead and begin again.

Arevalo M et al., Contraception, 2002;65:333-338.

 Cervical Mucus Method
no unprotected
intercourse

Early Transitional Highly Fertile

Mucus Mucus Mucus

• Slight amount • Increasing • Profuse

• Thick amounts • Thin
• White • Thinner • Transparent
• Sticky • Cloudy • Stretchy
• Holds its shape • Slightly stretchy

Stanford JB, et al. Obstet Gynecol. 2003;101:1285-1293.

 Fertility Awareness Methods
pros & cons
• Pros
– Essentially free
– No medical side effects
– Does not interrupt sexual activity
– Woman gains awareness about her body and natural
cycles, which can increase comfort w/sexuality
– Acceptable to certain religions: Muslims, Catholic Church
• Cons
– No STI protection
– Requires some degree of discipline in order to keep track
of calendar/charts, etc.
– Need to abstain from intercourse or use a backup
method during fertile days
 Permanent
Contraceptive
Methods

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 Sterilization
• Procedure performed on a man or a
woman permanently sterilizes
• Female = Tubal Ligation
• Male = Vasectomy
 Tubal Ligation
• Surgical procedure performed on a woman
• Fallopian tubes are cut, tied, cauterized, prevents eggs from
reaching sperm
• Failure rates vary by procedure, from 0.8%-3.7%
• May experience heavier periods

Surgical sterilization which

permanently prevents the
transport of the egg to the uterus
by means of sealing the fallopian
tubes is called tubal ligation,
commonly called "having one's
tubes tied." This operation can be
performed laparoscopically or in
conjunction with a Cesarean
section, after the baby is delivered.
Tubal ligation is considered
permanent, but surgical reversal
can be performed in some cases
Laparoscopy ‘band-aid’
Sterilization
 Vasectomy
• Male sterilization procedure
• Ligation of Vas Deferens tube
• No-scalpel technique available
• Faster and easier recovery than a tubal
ligation
• Failure rate = 0.1%, more effective than
female sterilization
During a vasectomy (“cutting the vas”) a urologist cuts
and ligates (ties off) the ductus deferens. Sperm are still
produced but cannot exit the body. Sperm eventually
deteriorate and are phagocytized. A man is sterile, but
because testosterone is still produced he retains his sex
drive and secondary sex characteristics.
 Take Home Message
• Contraceptive methods are temporary and
permanent
• Temporary include hormonal, non hormonal
pills, barrier and mechanical methods (IUDs)
and information based methods
• Permanent methods are male and female
sterilization
• Most effective temporary methods are
hormonal and IUDs; and permanent
sterilization

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Thank you and Queries are
Welcome!