Dr Jehan Hamadneh

CONSULTANT
Gynecology endocrinology
and
Reproductive Medicine

No single method of birth control is the

best one. Each has its own advantages
and disadvantages.
Abstinence is the only 100% effective way
to prevent pregnancy and STDs.
A patient's choice of contraceptive method
involves factors such as efficacy, safety, non
contraceptive benefits, cost, and personal
considerations.

1. Barrier Methods
Methods that physically or chemically
block sperm from reaching an egg AND
provide a BARRIER between direct skin
to skin contact.

Diaphragm
Cervical cap
Female condom

The Reality female condom is a polyurethane

sheath intended for one-time use, similar to
the male condom.
It contains 2 flexible rings and measures 7.8
cm in diameter and 17 cm long. The ring at
the closed end of the sheath serves as an
insertion mechanism and internal anchor that
is placed inside the vaginal canal. The other
ring forms the external patent edge of the
device and remains outside of the canal after
insertion.

 Female

condoms are 79 to 95 percent

effective
Worn by the woman, barrier to the passage of
semen into the vagina
It can be inserted up to eight hours before
sexual intercourse (though not necessary)))

Advantages
Provides some protection to the labia and
the base of the penis during intercourse.
The sheath is coated on the inside with a
silicone-based lubricant.
It does not deteriorate with oil-based
lubricants.

Disadvantages
The lubricant does not contain spermicide.
The device is difficult to place in the vagina.
The inner ring may cause discomfort. Some
users consider the female condom
cumbersome.
The female condom may cause a urinary
tract infection if left in vagina for a
prolonged period

Is a shallow latex cup with a spring mechanism in

its rim to hold it in place in the vagina.
Diaphragms are manufactured in various diameters.
A pelvic examination and measurement of the
diagonal length of the vaginal canal determines the
correct diaphragm size. It is inserted before
intercourse so that the posterior rim fits into the
posterior fornix and the anterior rim is placed
behind the pubic bone.
Spermicidal cream or jelly is applied to the inside
of the dome, which then covers the cervix.

Once in position, the diaphragm provides effective

contraception for 6 hours. If a longer interval has
elapsed without removal of the diaphragm, fresh
spermicide is added with an applicator. After
intercourse, the diaphragm must be left in place
for at least 6 hours.
Diaphragm - Prevents pregnancy by acting as a
barrier to the passage of semen into the cervix
Efficacy
Effectiveness of the diaphragm depends on the
age of the user, experience with its use, continuity
of use, and the use of spermicide. The typical-use
failure rate within the first year is estimated to be
20%.

Advantages
Does not require hormonal usage. Contraception is
controlled by the woman.
may be placed by the woman in anticipation of
intercourse.
Disadvantages
Prolonged use during multiple acts of intercourse
may increase the risk of urinary tract infections.
Usage for longer than 24 hours is not recommended
due to the possible risk of
toxic shock syndrome (TSS).
The diaphragm requires professional fitting. Poorly
fitted diaphragms may cause vaginal erosions.

Diaphragms have a high failure rate. Use of a

diaphragm requires brief, formal training.
may develop an odor if not properly
cleansed.

Is a cup-shaped latex device that fits over the base

of the cervix. T
he cap must be filled one third full with
spermicide prior to insertion.
It is inserted as long as 8 hours before coitus and
can be left in place for as long as 48 hours.
A cervical cap acts as both a mechanical barrier to
sperm migration into the cervical canal and as a
chemical agent with the use of spermicide.

Effectiveness depends on the parity of women due

to the shape of the cervical os. With perfect use in
the first year, the failure rate for nulliparous
women is 9%, as opposed to 20% in parous women.
Advantages
It provides continuous contraceptive protection for
its duration of use regardless of the number of
intercourse acts. Unlike with the diaphragm,
additional spermicide is not necessary for repeated
intercourse

Disadvantages
Cervical erosion may lead to vaginal spotting.
A theoretical risk of TSS if it is left in place longer
than the prescribed period.
Requires professional fitting and training for use.
Severe obesity may make placement difficult.
It has a relatively high failure rate.
Candidates must have history of normal results on
Papanicolaou (Pap) tests.

Creams, Films, Foams, Jellies, Pessaries, Sponges

nonoxynol-9 or octoxynolx
must be inserted into the vagina prior to each
coital act.
Spermicides prevent sperm from entering the
cervical os by attacking the sperm's flagella and
body, reducing their mobility, and disrupting their
fructolytic activity, thereby inhibiting their
nourishment.

Advantages
The lubrication provided by spermicides may
heighten satisfaction in both partners.
the ease of application. Either partner can
purchase and apply spermicide because it is easily
accessible, available over the counter, and
inexpensive.
Applying spermicide requires minimal patient
education. It augments contraceptive efficacy of
the cervical cap and diaphragm. Spermicides
produce no adverse systemic effects.

Disadvantages
Spermicides provide minimal protection from
STDs.
Insertion may be uncomfortable for some
couples.
Vaginal irritation is possible, and spermicides
may cause an allergic reaction.

3. Hormonal Methods
Oral contraceptive - Combined oestrogen/
progestogen
- Progestogen only
Depot progestogens Injections
- Subcutaneous silicone
implants
Vaginal
- Silicone rings releasing oestrogen
& progestogen

3. Intra Uterine Devices

Inert
Copper bearing
Progestogen releasing.
4. Natural Methods
Breast feeding (while baby is totally breast
fed)/Lactational amenorrhea
Coitus interruptus
Natural family planning/Rhythm
One of the most widely used methods of fertility
regulation, particularly for persons whose religious or
cultural beliefs do not permit devices or drugs for
contraception. This technique involves periodic
abstinence, with couples attempting to avoid intercourse
during a woman's fertile period, which is around the time
of ovulation.

Techniques to determine the fertile period include

the calendar method, cervical mucus method, or
the symptothermal method.
The calendar method is based on 3 assumptions:
(1) A human ovum is capable of fertilization only
for approximately 24 hours after ovulation, (2)
spermatozoa can retain their fertilizing ability for
only 48 hours after coitus, and (3) ovulation
usually occurs 12-16 days before the onset of the
subsequent menses.

The menses is recorded for 6 cycles to

approximate the fertile period. The earliest
day of the fertile period is determined by the
number of days in the shortest menstrual
cycle subtracted by 18. The latest day of the
fertile period is calculated by the number of
days in the longest cycle subtracted by 11

Under the influence of estrogen, the mucus

increases in quantity and becomes
progressively more elastic and copious until a
peak day is reached. This is followed by
scant and dry mucus, secondary to the
influence of progesterone, which remains
until the onset of the next menses.
Intercourse is allowed 4 days after the
maximal cervical mucus until menstruation.

The basal body temperature of a woman is

relatively low during the follicular phase and
rises in the luteal phase of the menstrual
cycle in response to the thermogenic effect
of progesterone. The rise in temperature can
vary from 0.2-0.5C. The elevated
temperatures begin 1-2 days after ovulation
and correspond to the rising level of
progesterone. Intercourse can resume 3 days
after the temperature rise

Efficacy
The failure rate in typical use is estimated to
be approximately 25%.
Advantages
No adverse effects from hormones occur. This
may be the only method acceptable to
couples for cultural or religious reasons.
Immediate return of fertility occurs with
cessation of use.

Disadvantages
This is most suitable for women with regular
and predictable cycles.
Complete abstinence is necessary during the
fertile period unless backup contraception is
used.
This method requires discipline. The method
is not effective with improper use.
The failure rate is relatively high.
This method does not protect against STDs

5. Surgical Methods
with laparoscopy, laparotomy, or colpotomy
Laparoscopic sterilisation - Falope Rings
- Clips
- bands
segmental destruction with - Bipolar
diathermy
- Laser
Tubal ligation
suture ligation with partial salpingectomy.

6. Immunological Methods
- These are still at an investigative stage.

Condom
Vasectomy
Male oral contraception with androgens
and with cotton seed oil
Immunological contraception

Still at
investigative
.stage

 Male

condoms are 82 to 98 percent

effective at preventing pregnancy
Condoms can only be used once
Do not use oil-based lubricants such as
massage oils, baby oil, lotions, or petroleum
jelly.They will weaken the condom, causing
it to tear or break.
Good choices: Latex condoms and
polyurethane

One of the most popular mechanical barriers

provides the most effective protection of
the genital tract from sexually transmitted
diseases (STDs)

The failure rate of condoms in couples that use

them consistently and correctly during the first
year of use is estimated to be approximately 3%.
However, the true failure rate is estimated to be
approximately 14% during the first year of typical
use. This marked difference of failure rates
reflects errors in usage. Common errors with
condoms usage include failure to use condoms
with every act of intercourse and throughout
intercourse, improper lubricant use with latex
condoms (eg, oil-based lubricants), incorrect
placement of the condom on the penis, and poor
withdrawal technique.

Advantages
Condoms are readily available and are usually
inexpensive. This method involves the male
partner in the contraceptive choice. Condoms are
effective against both pregnancy and STDs.
Disadvantages
Condoms possibly decrease enjoyment of sex.
Some users may have a latex allergy. Condom
breakage and slippage decrease effectiveness. Oilbased lubricants may damage the condom

involves withdrawal of the entire penis from

the vagina before ejaculation. Fertilization is
prevented by lack of contact between
spermatozoa and the ovum..
Efficacy
The failure rate is estimated to be
approximately 4% in the first year of perfect
use. In typical use, the rate is approximately
19% during the first year of use.

Advantages
Include immediate availability, no devices,
no cost, no chemical involvement, and a
theoretical reduced risk of transmission of
sexually transmitted diseases (STDs).
Disadvantages
The probability ofpregnancyis high with
incorrect or inconsistent use.

Elevated prolactin levels and a reduction of

gonadotropin-releasing hormone from the
hypothalamus during lactation suppress
ovulation. This leads to a reduction in
luteinizing hormone (LH) release and
inhibition of follicular maturation. The
duration of this suppression varies and is
influenced by the frequency and duration of
breastfeeding and the length of time since
birth.

Mothers only need to use breastfeeding to be

successful; however, as soon as the first
menses occurs, she must begin to use
another method of birth control to avoid
pregnancy.

Efficacy
The perfect-use failure rate within the first 6
months is 0.5%. The typical-use failure rate
within the first 6 months is 2%.

Advantages
Involution of the uterus occurs more rapidly.
Menses are suppressed. can be used
immediately after childbirth. facilitates
postpartum weight loss.
Disadvantages
Return to fertility is uncertain.
Frequent breastfeeding may be inconvenient.

It was first introduced in 1960

It has been used by millions of women worldwide
Two types of estrogens are used:ethinyl
estradiole
& mestranol. Mestranol is converted in the body
to ethinyl estradiole
Several progestins of varying potency are used in
the combined OCP
Types of progestins in COCP
Estrane Norethindrone, ethynodiol diacetate
Gonane Levonorgestrel, desogestrel,
norgestimate ( gonans more potent)

Progestins are also classified to 1st, 2nd, 3rd,

generation progestins
2nd levonorgestril
3rd desogestril & gestodene
Norgestimate partly converted to
levonorgestril included in 2nd or 3rd gp
Newer progestins desogestril &
norgestimate have little or no androgenic
activity
VTE is 2 folds higher in preparation
containing 3rd generation progestins when
compared to 2nd generation

Dosage & regimen

Estrogen 20-35g/ day
Better cycle control with higher estrogen dosage
but the efficacy is the same
Used for 3 wks with one wk gap when
menstruation occurs
Formulations
Monophasic contains fixed amount of estrogen
& progestin
Biphasic a fixed amount of estrogen, while the
progestin increases in the 2nd half of the cycle
Triphasic the amount of estrogen may be fixed
or variable, while the amount of progestin
increases in 3 equal phases

Efficacy
COCP is highly effective 99.9% in preventing
pregnancy.
30% of women miss 3 or more pills in the 1st cycle
of use
47% miss 1 or more pills
body Wt may the efficacy of the pills ( not
proven)
Indication
Any women seeking a reversible, reliable, coitallyindependent method of contraception, in the
absence of contraindications

The major development in OCPs is the

reduction in the dosage of ethinyl estradiol
to 20 mcg to improve the safety and reduce
adverse effects.
These lower doses are associated with a
decrease in the incidence of estrogen-related
adverse effects, such as weight gain, breast
tenderness, and nausea.

Mechanism of action
Suppression of gonadotropin secretion
inhibition of ovulation (main mechanism)
Development of endometrial atrophy making it
unreceptive to implantation
Production of viscous Cx mucous that impede
sperm transport
Possible effect on the secretions & peristalsis
of the fallopian tube interfering with ovum &
sperm transport

< 6 Wk postpartum if breastfeeding

Smoker , > 35 Y of age
HPT systolic 160 mm Hg or diastolic 100 mm Hg
Current or past Hx of venous thromboembolism VTE
Ischemic heart disease
Hx of cerebrovascular accident
Complicated valvular heart disease (pulmonary HPT,
atrial fibrilation, subacute bacterial endocarditis)
Migraine headache with focal neurological symptoms
Current breast cancer
Diabetes with retinopathy/ nephropathy/ neuropathy
Severe liver cirrhosis
Liver tumour ( adenoma or hepatoma)

Relative contraindications

Adequately controlled HPT

HPT systolic 140-159 mm Hg, diastolic 90-99
mm Hg
Migraine headache > 35 Y of age
Currently symptomatic gallbladder disease
Mild liver cirrhosis
Hx of COCP related cholestasis
Medications that might interfere with OCP
metabolism

The incidence of pill failure that results in

pregnancy is approximately 1-2% per year (12 pregnancies per 100 women per year of
use) i

Non-contraceptive benefits

Cycle regulation
menstrual flow
anemia

dysmenorrhea
acne
hirsutism
ovarian ca 50%
after 5 Y of use
bone mineral
density
reduce and sometimes
eliminate
mittelschmerz.

endometrial ca 50%
risk of fibroids
Possibly ovarian cysts
Possibly benign breast
disease
Possibly colorectal ca
incidence of salpingitis
incidence or severity of
premenstrual syndrome
peri-menopausal
symptoms
Ectopic pregnancies are
prevented by the cessation
of ovulation.

Oral contraceptives are noted to prevent epithelial

ovarian and endometrial carcinoma. Studies have
noted an approximate 40% reduced risk of malignant
and borderline ovarian epithelial cancer. This
protection appears to last for at least 15 years
following discontinuation of use and increases with
duration of use.
Use of oral contraceptives is associated with a 50%
reduction of risk of endometrial adenocarcinoma.
Protection appears to persist for at least 15 years
following discontinuation of use.

Hepatocellular adenoma:
Although these tumors are histologically
benign, their danger lies in the risk of
rupture of the capsule of the liver, leading to
extensive bleeding and, possibly, death.
With the current low-dose oral contraceptive
combination, the risk for liver tumors is
much lower.

Adverse effects include nausea, breast

tenderness, breakthrough bleeding,
amenorrhea, and headaches.
Use of low-estrogen oral contraceptives is
associated with a lower risk of
thromboembolism
Oral contraceptives have a dose-related
effect on blood pressure

A weak association may exist between oral

contraceptive use and squamous cell cancer
of the cervix. Important risk factors include
early sexual intercourse and exposure to the
human papillomavirus. The overall consensus
is that if indeed oral contraceptive use
increases the risk of cervical neoplasia, it is a
minimal risk. Thus, women who use oral
contraceptives should have annual Pap tests.

Limited data have demonstrated that oral

contraceptive use does not lead to coronary
atherosclerosis.
In rare cases in which myocardial infarcts have
been found, the cause has been noted to be of
thrombotic rather than of atherosclerotic etiology.
In general, a woman's habits are more significant
than the use of oral contraceptives in determining
her risk for cardiovascular disease. The patient
who is sedentary, is overweight, smokes heavily, is
hypertensive, is diabetic, or has
hypercholesterolemia is clearly at risk.

Minor side-effects commonly occure during the 1st

3 cycles & may lead to unnecessary
discontinuation
1. Irregular bleeding (breakthrough bleeding/
spotting)

10-30% in the 1st month of use

improves with time over 3 cycles

amenorrhea 2-3% of the cycles

2. Breast tenderness & nausea

Improve with time

Less with lower estrogen dosage

3-Wt gain
Placebo controlled trials have failed to show any
association between wt gain & COCP
4-Mood changes
Women report depression & mood changes
Placebo controlled trials have failed to show any
significantly increased risk of mood changes with
COCP

1-Venous thromboembolism
VTE 3-4 X higher in users than nonusers
Absolute risk of VTE in COCP users
1-1.5/10 000/year
Risk of VTE is higher during the 1st year of use than
subsequent years
Incidence of VTE in nonpregnant women is 0.3/
10000/year at 20-24 Y------0.6 at 40-44 Y
Incidence of VTE in pregnancy is 13/ 10000 deliveries
The risk is attributed to the estrogen component of
the pill & decline with lower dosage

2- Myocardial infarction
In the past with pills containing >50g
ethinyl estradiole --- 3X in MI

Recent studies with pills containing < 50g

ethinyl estradiole ----- No significant risk

3-Stroke
Some studies showed 2X risk of stroke
Smoking & HPT risk of stroke
4-Gallbladder disease
COCP secretion of cholic acid in bile incidence
of gallstone formation
5-Breast cancer
Still controversial
A large meta-analysis 1996 significant risk of
breast ca in women currently taking the COCP & in
the 1st 10 Y after discontinuing it

5-Breast cancer
Cumulative breast ca risk up to age 35 is 2 / 1000
with COCP --------------------------------------- 3 / 1000
It is not known whether this is due to the pills or due
to delaying the 1st full term birth
More recent study > 9000 women no significant
in breast ca risk
No risk with different dosage of estrogen, longer
periods of use, or with different progestin components
No risk in Pt with family Hx of breast ca
No risk in Pt who started using the pills at an
earlier age
risk in Pt who carry BRCA1, BRCA2 genes

Although the consensus states that oral

contraceptives can lead to breast cancer, the
risk is small and the resulting tumors spread
less aggressively than usual.

6-Cervical cancer
One study risk of Cx ca in long term COCP
users who are HPV positive
A review of 28 studies of women with Cx ca risk
of Cx ca with duration of COCP use
Probably due to risk of HPV (a major risk factor
for cx ca) that might be related to sexual behavior
which differs in users & non users of COCP
Another study HPV + ve women follwed up for 10
years showed no increased risk

Women on COCP should have periodic pill breaks

Fact this would risk of unwanted pregnancies &
cycle iregularities

COCP affects future fertility

Fact fertility restored 1-3 M after stopping the
pills

COCP causes birth defects if a woman becomes

pregnant while taking it
Fact There is no evidence that it causes birth
defects

COCP must be stopped in all women >35 Y

Fact Healthy non-smoking women can continue
taking the pills untill menopause

COCP causes acne

Fact it improves acne due to circulating free
androgens

Patient assessment
A thorough Hx to exclude contraindications,
smoking & medications
BP
Pelvic exam not mandatory before prescribing
COCP
No routine lab screening is required
Counselling
Instructions on how to use the pills
To start in the 1st 5 days of the cycle
Quick start method any day of the cycle
requires the use of back up method of
contraception for the 1st wk

Women who use 21 day preparation should

be cautioned not to exceed the 7 day pillfree interval between packs
Discussing what to do if a pill is missed
Information about side-effects, risks & noncontraceptive benefits of COCP
Discussing warning signs & when to come to
the hospital
The use of COCP in a continuous fashion
COCP must be stopped 4 wks prior to major
surgery or users should be given
antithrombotic prophylaxis

1-Breakthrough bleeding
To continue on the same pills with the
expectation that it will improve with time
(rather than switching to another preparation)
If bleeding persists beyond 3 M (or new onset of
bleeding in a long term user ) rule out other
causes of bleeding:
-irregular taking of the pills
-pregnancy
-infections
-uterine or Cx pathology
-malabsorption/ diarrhea , vomitting
-concomitant use of medications

Management of breakthrough bleeding

Oral estrogens: premarine 1.25 mg or estradiole -17 /7 days

Change the another preparation with different progestin

2-Missed pills
<12 hrs Take the pill as soon as you remember ( this means taking 2 in 1
day)
>12 hrs .use another method for 1 week
If 2 pills in a row missed in the 1 st 2 wks of the pack take 2 /day for 2
days
If 2 pills in a row missed in the 3 rd wk of the pack through the remainder
of the pack & start a new one / use back up contraception in the first 7
days of the new pack
If 3 pills in a row missed follow steps above

If intercourse occurred after missing a pill use emergency contraception

3-Amenorrhea
It occurs in 2-3% of COCP users
Pregnancy should be ruled out
It is not dangerous no need for Rx
If not acceptable by Pt change preparation
Add oral estrogen for 10 days
4-Chloasma
Darkening of the facial skin
Changing to another preparation will not help
It may never completely disappear
Use of sunscreen to prevent further darkening

5-Breast tenderness & galactorrhea

Often resolves with continued use
caffeine intake may help
estrogen content
Galactorrhea is rare if it happens check
prolactin level
6-Nausea
with time
Taking the pill with food or bedtime
estrogen content
If it occurs in a long time user rule out pregnancy
7-Pregnancy
Pills must be stopped immediately
There is no risk of birth defects

Ethinyl estradiole is metabolized at several sites:

1-Sulphated at the intestinal wall
2-Hydroxylated in the liver then conjugated with
glucuronides & pass to enterohepatic circulation
Anticonvulsants (phenytoin or carbamazepine)
women should use 50 g E estradiole pill

Monitor phenytoin level as COCP may inhibit its

metabolism
Rifampicin & griseofulvin contraceptive failure

Other antibiotics do not appear to affect the

efficacy of COCP

Delivers 150g norgestimate & 20 g E estradiole

daily
One patch is applied weekly for 3 wks followed by
one patch-free-wk
Pearl index with perfect use o.7
with typical use 0.88
Women weighing more than 90 kg risk of
pregnancy
Mechanism of action similar to COCP
Irregular bleeding in the 1st M of use is more 18% for
the patch than COCP 11% / Amenorrhea is rare
Breast symptoms are more 22% in the 1st 2 cycles of
the patch use than COCP use
Local skin reaction 20%
This skin patch is worn on the lower abdomen,
buttocks, or upper body

Advantages include greater compliance and

decreased adverse effects, such as nausea
and vomiting, due to the avoidance of the
first-pass effect.

However, the patch may cause skin irritation,

and, if it is removed unnoticed, such as from
showering, this may compromise efficacy.

A flexible transparent ring 54 mm diameter /4

mm cross-sectional diameter
Releases 15g E estradiole & o.12 mg of
desogestrel (etonogestrel)/ day
Ring is used for 3 wks continuous followed by one
ring-free wk
Irregular bleeding 6.4 % less than COCP
especially in the 1st cycle
Headache 11.8%, nausea 4.5%, breast tenderness
2.8%
Vaginitis 13.7% (5% Rx related), coital problem or
expulsion 1-2.5%

The ring contains 11.7 mg of etonogestrel

and 2.7 mg of ethinyl estradiol. It releases
120 mcg of etonogestrel and 15 mcg of
ethinyl estradiol each day. The hormones are
released slowly and are absorbed directly by
the reproductive organs

The ring can be inserted any time during the first 5

days of the menstrual cycle.
The ring should be placed in the vagina even if the
woman has not finished bleeding, and she should
use a backup contraceptive method for 7 days.
A new ring should be inserted each month. If the
ring comes out during the first 3 weeks of use, it
should be washed with lukewarm water and
replaced.

If the ring-free interval is more than 3 hours,

a backup contraceptive method should be
used for 7 days.
The ring should never be left in the vagina
for more than 4 weeks. If left in for more
than 4 weeks, pregnancy should be excluded
before inserting a new ring and a backup
contraceptive method should be used for 7
days after inserting a new ring.

Advantages
NuvaRing is highly effective because it results in
complete suppression of ovulation. The steady
release of hormone provides exceptional cycle
control. The ring is a very effective reversible
method of birth control.
The ring delivers the lowest dose of ethinyl
estradiol compared with other combined hormonal
contraceptives. Unlike combined oral
contraceptives, the adverse effects of nausea and
vomiting are avoided with ring use

Because daily intake is not a component of

NuvaRing contraception, because it is easily
inserted and removed by the woman herself,
and because return of fertility is rapid upon
discontinuation, NuvaRing is a highly
acceptable method for women and their
partners.
Because the hormones are absorbed directly
into the blood through the vaginal mucosa,
the hepatic first-pass metabolism of
progestin is prevented.

Disadvantages
Adverse effects include headaches and
vaginal irritation or discharge.
The ring may accidentally slip out during
intercourse and either the user or the
partner may feel the ring during sexual
intercourse.
Contraindications are similar to those of
combined oral contraceptiv

 It

is 91 to 99 percent effective at preventing

pregnancy

Ring

goes inside vagina up around the cervix

This method does not protect from HIV or
other STDs.

Monthly injectable contraceptive composed

of 5 mg estradiole cypionate & 25 mg
medroxyprogestrone acetate

Less breakthrough bleeding

Amenorrhea 14.6% compared to 3.3 in COCP

users

Wt gain 4 pounds/year

Introduced in 1967 & used by millions of women

worldwide
Highly effective with a failure rate < 0.3% / year

Mechanism of action
Inhibiting the secretion of pituitary gonadotropins
suppression of ovulation *1ry mechanism*
viscosity of Cx mucous
Induces endometrial atrophy

Any women seeking reliable, reversible, coitally

independent method of contraception in the
absence of contraindications
Women who have difficulty complying with other
methods / it does not require daily attention
Women with contraindication to estrogens
Women >35 Y who smoke
Women with migraine headache
Women who are breastfeeding
Women with endometriosis
Women with sickle cell disease
Women taking anticonvulsant medications
Mentally handicapped women

Absolute contraindications
Pregnancy
Unexplained vaginal bleeding
Current breast ca
Relative contraindications
Severe liver cirrhosis
Active viral hepatitis
Benign hepatic adenoma

Amennorrhea (55-60% at 12 M / 68% at 24 M ) with

subsequent reduction in dysmenorrhea & anemia
the failure rate is 0.3%.
risk of endometrial ca
symptoms associated with endometriosis, PMS, &
chronic pelvic pain
incidence of seizures
Possible risk of PID
Possible incidence of sickle cell crisis

Advantages
DMPA does not produce the serious adverse
effects of estrogen, such as
thromboembolism.
The risks of endometrial and ovarian cancer
are decreased.
It contains no estrogen, thus making it
suitable for women who cannot or will not
take estrogen products.
It also is safe for breastfeeding mothers

1- Menstrual cycle disturbance

Irregular bleeding in frequency & amount over time
Abnormally heavy or prolonged occurred only in 1-2%
Amennorrhea 55-60% at 12 M
68%
at 24 M
pproximately 70% of former users desiring pregnancy
conceive within 12 months, and 90% of former users
conceive within 24 months.
2-Hormonal side effects
Headache 17%
Acne
libido
Nausea
Breast tenderness

3-Weight gain
56% Wt ( mean gain 4.1 kg) possibly through
appetite stimulation & a mild anabolic effect
- 2.5 kg in 1st Y
-3.7 kg in 2 Y
-6.3 kg in 4 Y
44% Wt or maintained (mean loss 1.7 kg)
4-Mood effects
Prospective studies did not demonstrate
depressive symptoms
Some women discontinue use because of mood
changes

1-Delayed return of fertility

An average of 9 months delay before restoration of
full fertility after last injection
Rate of conception 50% at 10 M, 90% at 24 M
ther adverse effects, such as weight gain, depression,
and menstrual irregularities, may continue for as long
as 1 year after the last injection.
2-Reduction in bone mineral density
A mean loss of BMD at the lumbar spine 0.87-3.5%
Does not induce osteoporosis
It improves after discontinuation of use
bone loss from using Depo-Provera "may not be
completely reversible" even after stopping the drug.
3-VTE, CVD, Stroke No risk

Not to use Depo-Provera on a long-term

basis unless all other methods were
inadequate.
A subcutaneous version of the drug is now
available (depo-subQ provera 104) that
delivers a lower dose of
medroxyprogesterone acetate(MPA) than
does the intramuscular formulation (104 mg
vs 150 mg). home self-injections, and the
lower dose could decrease suppression of
pituitary function and ovarian estradiol
production. Further study is needed.

150 mg IM every 12 Wks

Started during the 1st 5 days of menses or within

5 days of stopping COCP

Effective within 24 hrs of injection if given during

the 1st 5 days of the cycles

If given later than D5 of the cycle back up

method of contraception must be used for 1 wk

1- Menstrual cycle disturbance

If irregular bleeding persists after the 1st 6 M of use
rule out other causes of abnormal bleeding
Management options
DMPA dosage 225-300 mg for 2-3 injections
interval between dosage
Supplemental estrogen therapy :
0.625 conjugated equine estrogen po 28 days
1-2 mg 17-estradiole po 28 days
Transdermal estrogen 50-100 g 17-estradiole patch
for 25 days
Nonsteroidal anti-inflammatory ibuprofen 400-800
mg bd for 10 days
Adding COCP for 1-3 M

2-Late injection
<14 wks since last injection it can be given
14 wks since last injection
-ve serum hcg, no intercourse for last 10 days
give the injection
back up contraception must be used for 2 wks
14 wks since last injection
-ve serum hcg,intercourse within the last 10 D
give the injection
back up contraception must be used for 2 wks
Repeat serum hcg 2 wks
Not teratogenic if inadvertently given during
pregnancy

Package contains 28 tab

Started on the 1st day of the menstrual cycle/ or
any day if pregnancy excluded
Must be used at the same time every day within 3
hrs
A back up contraception must be used for 7 days
Norethindrone 0.35 mg micronor
Must be used continuously no pill-free interval
Perfect use failure rate 0.5%
Typical use failure rate 5-10% (It must be taken
the same time every day)
It can be used immediately postpartum with no
effect on lactation

lower doses of progestin than combined oral

contraceptives. One formulation contains 75
mcg of norgestrel. The other has 350 mcg
ofnorethindrone.

Indications
It can be used for any women seeking
reliable, reversible, coitally independent
method of contraception in the absence of
contraindications
Women with contraindication to estrogen
Women > 35 Y who smoke
Women having migraine headache with
neurological symptoms
Women who have unwanted side-effects of
COCP
Breast-feeding women

Mechanism of action
1-Main mechanism is alteration of Cx mucous
volume of mucous
viscosity
alter its molecular structure
Little or no sperm penetration
Sperm motility is impaired fertilization
2- Ovulation is suppressed in 60% of the women.
suppression of ovulation (not uniformly in all cycles.
a reduction in cilia motility in the fallopian tube, thus
slowing the rate of ovum transport
3-Endometrial changes implantation

Absolute Contraindications
Pregnancy
Current breast cancer
Relative Contraindications
Active viral hepatitis
Liver tumors

Non contraceptive benefits

menstrual flow
10% amenorrhea
dysmenorrhea, PMS
Side-effects
Irregular bleeeding
spotting 12% 1st month
--3% 18 months
40 % continue to have regular cycles
Hormonal side-effects
Headache, bloating, acne, breast tenderness,
nausea

Unlike DMPA, fertility is immediately

reestablished after the cessation of
progestin-only oral contraceptives.

Risks
Not associated with any major morbidity
No risk of VTE, stroke or MI
Myths & misconception
It can only be used with breast feeding
Fact It can be used in any women seeking
reliable, reversible method of contraception
POP is not an effective method of contraception
Fact When used correctly it is safe & effective
with a failure rate of only 0.5%

1-Irregular bleeding
A common side effect
Pregnancy, infection & genital pathology must be
ruled out
Rx options
Non steroidal anti-inflammatory for 10 days
Switching toCOCP
Adding a short course of estrogen
0.625 mg conjugated equine estrogen
(premarine) for 28 days
1-2 mg micronized 17-estradiole28 days
Transdermal 50-100 g 17-estradiole patch 25
days
Antiprogestinic agents mifepristone

2-Missed pill
To be taken as soon as possible
Next pill to be taken at the regular time
If delayed > 3hrs use back up
contraception for 48 hrs
If 2 or more pills missed in a row 2
pills/day for 2 days back up contraception
for 48 hrs
Emergency contraception must be used if
intercourse occurred after a missed pill
3- Drug interactions anticonvulsants may
effectiveness of POP

NORPLANT Levonorgestril
Implanon Etonogestrel
Highly effective failure rate 0.1% / year
NORPLANT 6 rods implanted under the skin
effective for 5 years
Implanon One rod effective for 3 years
Reversible contraception
Mechanism of action
Suppression of ovulation
Endometrial atrophy
Rendering Cx mucous impermeable to sperms
Prolonged irregular bleeding the major side
effect

levonorgestrel implants (Norplant) in 1990. This

method consists of 6 silicone rubber rods, each
measuring 34 mm long and 2.4 mm in diameter and
each containing 36 mg of levonorgestrel. The
implant releases approximately 80 mcg of
levonorgestrel per 24 hours during the first year of
use-. Contraceptive protection begins within 24
hours of insertion if inserted during the first week
of the menstrual cycle. The rods are inserted
subcutaneously, usually in the woman's upper arm,
where they are visible under the skin and can be
easily palpated

The mechanism of action is a combination of

suppression of the LH surge, suppression of
ovulation, development of viscous and scant
cervical mucus to deter sperm penetration,
and prevention of endometrial growth and
development.
Efficacy
The contraceptive efficacy of the method is
equivalent to that of surgical sterilization.
Overall, pregnancy rates increase from 0.2%
in the first year to 1.1% by the fifth year.

Advantages
The longevity of its effectiveness.
Its effectiveness is not related to its use in regards
to coitus.
Exogenous estrogen is absent.
Prompt return to the previous state of fertility
occurs upon removal.
No adverse effect on breast milk production occurs.

Disadvantages
A minor surgical procedure is necessary for
insertion.
Difficulty in removal.
Menstrual irregularities are common along with
other adverse effects, including headaches, mood
changes, hirsutism, galactorrhea, and acne.
Appropriate candidates are women who are
postpartum or breastfeeding, women who have
difficulty with contraceptive compliance, women
in whom pregnancy is contraindicated due to a
medical condition, and patients with
contraindications to the use of estrogen.

Absolute contraindications include active

thrombophlebitis or thromboembolic disease,
undiagnosed genital bleeding, acute liver disease,
benign or malignant liver tumors, known or
suspected breast cancer, and a history of
idiopathic intracranial hypertension.
Relative contraindications include heavy cigarette
smoking, a history of ectopic pregnancy, diabetes
mellitus, hypercholesterolemia, severe acne,
hypertension, and a history of cardiovascular
disease, severe vascular or migraine headaches,
and severe depression.

Another FDA-approved implant is the 2-rod

levonorgestrel system, termed Norplant II or
Jadelle. Each rod is 4.4 cm long. Norplant II
is approved for 3 years of use but has been
shown to be effective for as long as 5 years..

Implanon is a single-rod implant that is 4 cm long

and 2 mm in diameter. It consists of 68 mg
ofetonogestrelin an ethylene vinyl acetate
copolymer core. Etonogestrel is a biologically
active metabolite of desogestrel. Desogestrel is
significantly more potent than levonorgestrel; a
serum concentration of 0.09 ng/mL can inhibit
ovulation in most women.
Serum concentrations are adequate for
contraception coverage for approximately 3 years..
etonogestrel implant may be less effective in
women who are overweight.

Compared with the Norplant system, Implanon is

associated with a higher frequency
ofamenorrheaand oligomenorrhea, a decrease in
the prevalence of frequent and prolonged
bleeding, and a decrease in the frequency of
adverse effects such as weight gain, headache,
and acne.
When the rod is removed, the return to fertility is
rapid, with the return of ovulation within 3 weeks.
Implanon is not associated with loss of bone
mineral density (BMD).

Nonmedicated IUCD ( Multiload)

Copper IUD( Nova T)
Levonorgestrel releasing IUD (Mirena)
Efficacy
Failure rate of Nova T 1.26 % /year
----------------Mirena 0.09 % /year
Ectopic pregnancy rate 0.25 %/year
------------------Mirena 0.02 %/year
Effective for 5 years

Inert IUDs are IUDs with

nobioactivecomponents; they are made of inert
materials likestainless steelorplastic.
They are less effective than copper or hormonal
IUDs, with a side effect profile similar to copper
IUDs.
Their primary mechanism of action is inducing a
localforeign body reaction, which makes the
uterine environment hostile both tosperm and
toimplantationof an embryo.

The T-shaped progesterone-releasing IUD

Progestasert, contains 38 mg of progesterone and
minimal amounts of barium sulfate for greater
visibility on x-ray films.
The vertical limbs are 36 mm long, and the
horizontal arms are 32 mm wide. It has a pair of
dark-blue double-strings that hang from the lower
limb.
Approximately 65 mcg/d of progesterone is
released from the progesterone form from a
reservoir in its stem. This is a sufficient amount of
hormone to last for 400 days; therefore, this IUD
must be replaced yearly

The Copper T380 was introduced in 1988.

The T-shaped IUD is made of polyethylene
with fine copper wire wrapped around the
vertical stem.
The string is clear or white and hangs from
the lower limb of the IUD. This device
consists of 308 mg of copper covering
portions of its stem and arms.
Contraceptive effectiveness continues for 10
years, after which time it must be replaced.

Mirena is similar in shape to the Copper T380 in that

it also consists of a small T-shaped frame with a
reservoir that contains levonorgestrel, a
progesterone.
This intrauterine system releases 20 mcg of
levonorgestrel per day into the uterine cavity for as
long as 5 years.
It consists of a polyethylene frame with a cylinder
containing a polydimethylsiloxane-levonorgestrel
mixture enveloping the vertical arm. The cylinder is
coated with a membrane that regulates the release
of the hormone. This model is also visible on x-ray
films.
The Mirena device now has FDA labelling for treating
menorrhagia as well

In January 2013, the FDA approved Skyla,

another T-shaped polyethylene device
designed to prevent pregnancy for 3 years,
during which time it releases a diminishing
dosage of levonorgestrel.
The Skyla IUD contains 13.5 mg of
levonorgestrel that releases at a rate of 14
mcg/day (after 24 days from insertion). The
release rate declines after 3 years to 5
mcg/day

The failure rate is 2% with Progestasert (the

progesterone form),
0.6% with the Copper T380,
and of 0.1 % with Mirena.

Advantages
IUDs produce no adverse systemic effects.
Ectopic pregnancies are reduced overall;
however, the ratio of extrauterine to
intrauterine pregnancy is increased if
conception does occur.
Menstrual blood loss and dysmenorrhea are
decreased with Progestasert.
Twenty percent of women experience
amenorrhea with Mirena.

Disadvantages
Risk of uterine perforation at the time of insertion.
Increased dysmenorrhea occurs with the Copper T380.
Increased menstrual blood loss occurs in the first few
cycles with use of the Copper T380 and Mirena IUDs.
Whether IUDs increase the risk of PID is controversial.
IUDs may be expelled unnoticed, and they do not
protect against STDs.

Prevention of fertilization the chief mechanism

Inhibition of implantation
Presence of foreign body & copper biochemical
& morphological changes in the endometrium
adversely affect sperm transport
Copper ion have direct effect on sperm mobility
in its ability to penetrate Cx mucous
Levonorgestrel releasing devices weak foreign
body reaction & endometrial decidualization &
glandular atrophy estrogen & progestrone
receptors are Cx mucous becomes thick &
impermeable to sperms ovulation may be
inhibited in some women

In the absence of contraindications may be

considered for any woman seeking a reliable,
reversible, coitally independent method of
contraception
Women seeking long term birth control
A method requiring less compliance
Women with contraindications to estrogen
Breast feeding women
Copper IUCD used for postcoital contraception
within 7 days
LNG- IUCD menstrual flow & cramping
suitable for women with menorrhagia &
dysmenorrhea

Copper IUD: Can stay for up to 10 years

Interferes with sperm, fertilization,
and prevents implantation
Hormonal IUD: Can stay for up to 5
years
It releases a small amount of hormone
each day

Absolute contraindications
Pregnancy
Current, recurrent or recent (within 3 M) PID or
sexually transmitted disease
Puerperal sepsis
Immediate post septic abortion
Severely distorted uterine cavity
Unexplained vaginal bleeding
Cx or endometrial ca
Malignant trophoblastic disease
Copper allergy/Wilson disease, Copper -IUCD
Breast ca LNG -IUCD

Relative contraindications
Risk factor for sexually transmitted diseases or HIV
Increased susceptibility to infection (eg, those with
leukemia, diabetes, valvular heart disease, or AIDS,women on corticosteroid Rx
48hrs- 4 wks postpartum
Ovarian ca
Benign gestational trophoblastic disease
History of ectopic pregnancy,

Nonmedicated IUCD or copper IUCD risk of

endometrial ca
LNG-IUCD menstrual blood loss 74-97%
improved Hb
LNG-IUCD users hysterectomy for
menorrhagia 64-80%
LNG-IUCD dysmenorrhea
--------------- protects against endometrial
hyperplasia in women on tamoxifen
-------------- beneficial effects in fibroid
related menorrhagia

1-Bleeding
Copper / non medicated IUCD
Irregular menstrual bleeding
amount of menstrual bleeding 65% in copper
IUCD users
NSAID or tranexamic acid menstrual blood
loss
The days of bleeding or spotting overtime 13
days in the 1st months 6 days at 1 year
Discontinuation due to bleeding 20%
LNG-IUCD
menstrualblood loss 74-97%
Spotting 16 days at 1 M 4 days at 12 M
Discontinuation due to bleeding 14%
Amenorrhea 16-35% at 12 M

2-Pain or dysmenorrhea
6% discontinue use due to pain
Pain may be physiological
LNG-IUCD dysmenorrhea
3-Hormonal LNG-IUCD
Depression
Acne
Headache
Breast tenderness
Low incidence ,maximal at 3 M then
No change in Wt

4-Functional ovarian cysts/ LNG-IUCD

30% of users
Resolve spontaneously

1-Uterine perforation
A rare complication at insertion
0.6-1.6/1000 insertion
Risk factors
Postpartum insertion
Inexperienced operator
Immobile uterus
Extremely ante or retro verted uterus
2-Expulsion
2-10% in the 1st year of use
Risk factors: postpartum insertion,
nulliparity,previous expulsion(30% chance)

3-Infection
Risk is only in the 1st few months after insertion
Inverse relation between infection & time since
insertion
4-Failure
If a woman become pregnant with an IUCD
exclude ectopic
Abortion is in women pregnant with IUCD in
place
Copper IUCD abortion 75% if left in situ
Live birth 89% if IUCD removed
Preterm delivery in women pregnant with IUCD
in place

IUCD risk of ectopic

Fact IUCD work primerly by preventing
fertilization
Ectopic in IUCD users : nonusers
0.02-0.25/100WY:0.12-0.5/100WY
IUCD risk of infertility
Fact Women who discontinue IUCD use concieve
at the same rate of women who never used IUCD
IUCD risk of long term PID
Fact after the 1st M the risk of infection is not
higher than non users/ PID < 2/ 1000 year of use
IUCD are not effective contraceptives
Fact LNG IUCD as effective as tubal ligation

Counselling
Inserted any time during a menstrual cycle once
pregnancy excluded
During menses exclude pregnancy & mask
insertion related bleeding
Infection & expulsion with insertion during menses
It can be removed any day of the menstrual cycle
If there is mucpurulent discharge Cx swabs must
be taken & insertion delayed
Antibiotic prophylaxis is not indicated

A follow up visit must be scheduled in 6 wks

then yearly
Women must be instructed to come if;
IUCD thread can not be felt
She feels the lower end of the IUCD
? Pregnant
Abdominal pain, fever or unusual discharge
Pain or discomfort during intercourse
Sudden change in menstrual period
Wants to remove the device or concieve

1-Lost string
Speculum exam
Exclude pregnancy
Cx canal explored
U/S
Plain X ray
2- Pregnancy
Exclude ectopic
If she wishes to continue the pregnancy
remove IUCD
If string missing u/s if in the uterus no
attempt to remove it

3-Amenorrhea /delayed menses

Exclude pregnancy
35% of LNG IUCD users have amenrrhea
4-Pain & abnormal bleeding
Exclude pregnancy, partial expulsion, perforation
NSAID may help
Bleeding overtime
If it persists or worsen removal
5-Difficulty removing IUCD
Cx dilatation
U/S
Hystroscopy

6-Sexually transmitted disease with IUCD in

situ
Antibiotics
Removal
7-Actinmycosis on PAP smear
It is a vaginal commensal
20% in Cx smears of copper IUCD users
3% in LNG-IUCD users
Removal is not necessary if asymptomatic
If symptomatic remove IUCD after starting
antibiotics / continue Ab Rx

Also known as the morning after pill

Copper IUCD can be inserted up 7 days after

intercourse
Levonorgestrel 0.75 mg , 2doses 12 hrly
or 1.5 mg single dose similar efficacy
Yuzpe method 2 doses 100g E estradiole & 500 g
levonorgestrel (Ovral)
Hormonal contraception must be started as soon as
possible max 5 days
Women should be evaluated for pregnancy if menses
does not occur after 21 days
Mechanism of action Hormonal contraception
interferes with ovulation
other mechanisms could be interference with sperm
mobility or transport, endometrial receptivity,
fertilization or zygot development

Most studies cite an effectiveness rate of 55-94%,

with the true effectiveness rate likely to be
approximately 75%.

Disadvantages
Adverse effects include nausea and emesis, minor
changes in menses, breast tenderness, fatigue,
headache, abdominal pain, and dizziness. Ectopic
pregnancy is possible if treatment fails.

Copper T380 Intrauterine Device

The Copper T380 IUD can be inserted as
many as 7 days after unprotected sexual
intercourse to prevent pregnancy.
Insertion of the IUD is significantly more
effective than either the ECP or MECP
regimen, reducing the risk of pregnancy
following unprotected intercourse by more
than 99%.

Effectiveness
Yuzpe 75% reduction in pregnancy
pregnancy rate 3.2%
LNG 89% reduction
pregnancy rate 1.1%
Effectiveness with delay between
intercourse & contraception
IUCD more effective 98.7%
Side effects
LNG have lower incidence of nausea(23 vs 50%),
vomitting (5.6vs 18.8%), dizziness (11.2vs16.7%),
fatigue (16.9vs28.8%)than Yuzpe

Candidates for emergency contraception include

reproductive-aged women who have had
unprotected sexual intercourse within 72 hours of
presentation independent of the menstrual cycle.

should only be used after no birth control was used

during sex, or if the birth control method failed,
such as if a condom broke
Should NEVER be used as regular birth control

No known absolute contraindications to any of

these methods have been described because
exposure to the high dose of hormones is short
lived. However, cases of deep vein thrombosis
have been documented in women using the ECP
method.

The ECP mode is marketed as Preven. It consists of

2 pills, which each contain of levonorgestrel and
100 mcg of ethinyl estradiol, ingested 12 hours
apart for a total of 4 pills. The first dose should be
taken within the first 72 hours after unprotected
intercourse; however, studies demonstrate
effectiveness if the pills are taken after that
period.

Only the progestinlevonorgestrelhas been

studied for the use in MECM.
It is marketed as Plan B.
Its treatment schedule comprises 1 dose of
750 mcg levonorgestrel taken as soon as
possible and no later than 48 hours after
unprotected intercourse and a second dose
taken 12 hours later.

Sterilization is considered an elective permanent

method of contraception.
Although both female and male sterilization
procedures can be reversed surgically, the surgery
is technically more difficult than the original
procedure and may not be successful.

Vasectomy:
This operation is done to keep a mans sperm
from going to his penis, so his ejaculate never
has any sperm in it that can fertilize an egg.
Operation is more simple than tying a
womans tubes
Vasectomy involves incision of the scrotal sac,
transection of the vas deferens, and occlusion
of both severed ends by suture ligation or
fulguration.

the procedure is usually performed with the

patient under local anesthesia in an outpatient
setting.
Complications include hematoma formation and
sperm granulomas.
Spontaneous resolution is rare. After sterilization,
remnant sperm remains in the ejaculatory ducts.
The man is not considered sterile until he has
produced sperm-free ejaculates as documented by
semen analysis. This usually requires 15-20
ejaculations.

Efficacy
The failure rate is approximately 0.1%.
Advantages
Vasectomy involves no hormones, is permanent, is
an outpatient procedure, is quick, and carries
minimal risk with regard to the procedure.
Disadvantages
Patients may regret their decision after the
procedure. Alternative contraception is required
until the ejaculate is deemed free of sperm.
Vasectomy does not prevent STDs. Short-term
discomfort occurs

Tubal ligation or tying tubes.

A woman can have her fallopian tubes
tied (or closed) to stop eggs from being
fertilized
Over time, the ends of the fallopian
tubes could fuse back together, and it
may be possible to get pregnant

failure Rates vary according to the procedure

performed.
The cumulative 10-year failure rate with each
method of tubal ligation is as follows: spring clip
method, 3.7%; bipolar coagulation, 2.5%; interval
partial salpingectomy, 2%; silicone rubber bands,
2%; and postpartum salpingectomy, 0.8%.
Advantages
Female sterilization does not involve hormones. It
is a permanent form of contraception.
No data indicate that change in libido, menstrual
cycle, or lactation occurs.
Female sterilization is usually a same-day
procedure.

It can be performed with laparoscopy,

laparotomy, or colpotomy
Disadvantages
Female sterilization is a procedure that
involves general or regional anesthesia.
It is permanent contraception, and patients
may regret the decision later, especially
women younger than 30 years.

The latest form of female permanent sterilization

is the Essure system.
prevents fertilization by interrupting the fallopian
tubes; however, the Essure system does not require
surgical incisions and can be performed with the
patient under local anesthesia.
It is performed hysteroscopically, and a
microinsert is placed directly into the fallopian
tubes.
During the first 3 months after the procedure, the
fallopian tube and the microinsert create a tissue
barrier that prevents sperm from reaching the egg.
After the 3-month period, patients must undergo a
hysterosalpingogram to ensure placement.

If male puts on a condom the wrong way, he

should take it off, and put it on the right
way? Yes or no?

NO!!! There could still be pre-ejaculatory

semen (WITH SPERM) on the outside, now
heading to the female.stds and pregnancy
are possible.

GET A NEW ONE!!!!

Put the following in order for the best

options in reducing your chances of STDs:

A) Male Condom
B) Birth Control Pill
C) Abstinence

Answer:
C) Abstinence
A) Male Condom
ONLY, because
B) Birth Control Pill does NOT protect against
STDs, only pregnancy!

 True

or False: A male condom can be used

again

FALSE:

ONLY ONCE- then remove QUICKLY

from the female, discard, and put another
condom on the penis if he wants to continue
to have sex again.

True or False: Birth control, when used

CORRECTLY EVERY TIME, is 100% effective

FALSE: Only ABSTINENCE is 100% effective

True or False:

Tubal ligation is an easier procedure for

females than a vasectomy is for males

FALSE: A vasectomy is a much more simple

and safe procedure

Which of the following is not placed INSIDE of

a female:
A) Female Condom
B) IUD
C) Birth Control Patch
D) Vaginal Ring

Correct Answer:

C) Birth Control Patch

An IUD can last for how long (depending on

what type)?
A) 1-4 years
B) 1-4 months
C) 5-10 months
D) 5-10 years

CORRECT ANSWER

D) 5-10 years

The birth control shot must be given every

_______ months:
A) 2
B) 3
C) 4
D) 5

Correct Answer:

B) 3