Gynecology 1.

FAMILY PLANNING: Contraception and Sterilization

OUTLINE
I. Introduction
II. Hormonal Contraception
III. Mechanical Contraception
IV. Barrier Contraception
V. Sterilization
_____________________________________________________________
REFERENCE: All included in this trans is from the lecturers ppt except
otherwise specified.
[1] Recording
INTRODUCTION
Mass sterilization camp in India

12 women died after mass sterilization (tubectomy/tubal ligation)

Possibility of toxic shock syndrome since rusty equipment were noted

The doctor performed 80 tubectomies on Saturday (November 8,

2014)

Women paid $23 for sterilization

Philippine population statistics 2008

Philippine population is still increasing1

Growth rate of 2.4%1

Birth rate, crude rate > per 1, 000 people: 24.16 per 1, 000 people (71st
out of 195 countries)

Contraception: 46% coverage (51st out of 89)

Infant mortality rate: 24.24 (84th out of 179)

Maternal mortality: 170 per 100,000 (49th out of 136); 162 per 100,000
(NSO)

Total expenditure on health as % of GDP: 2.9 (178th of 185), this is very

low!1
Fertility Rates, By Wealth Index

Women want 2-3 children only but theyre having more

Percentage using contraception among women age 15-49, married or in
union, 2011 [Percentage of Filipino women of reproductive age currently
using contraception]

The prevalence of use of traditional (withdrawal, rhythm) methods is

greater in the Philippines compared to other countries1

Contraception Prevalence Rate in the Philippines suggest need for

family planning
Maternal and fetal morbidity and mortality due to contraception

There is no data on deaths or morbidity due to contraception in the

Philippines and some women are afraid of using contraceptives1

On the other hand, 12% of maternal deaths were due to unsafe

abortion
o Maternal morbidity and mortality due to unintended pregnancy1
o Cytotec brought from Quiapo1
o Hilot inserts catheter into the uterus and put NSS1
Table 1. Statistics on Maternal Morbidity and Mortality in the Philippines
2008
1 3, 700 women
Died (1,600 did not want to become
pregnant
2 1, 000 women
Died from abortion and its
complications
3 90, 000 women
Hospitalized for complications

Dr. Bongala
Nov. 13, 2014

Table 2. 2008 Maternal Morbidity

Ratio
162 per 100,000 live births
Causes
1
Infection/ sepsis
2
Obstructed labor
3
Hemorrhage
4
Hypertensive disorders
5
Others: Abortion
Table 3. Failure Rates during First Year of Use in the United States
METHOD
PREGNANCY
Lowest Expected
Typical
No method
85%
85%
Combined pill (Progesterone 0.1
7.6
and estrogen)
Progestin only
0.5
3.0
IUDs
0.1
0.1

Levonorgestrel
0.6
0.8

Cu- T
Implant
0.05
0.2
Injectable
0.3
0.3
Female sterilization
0.05
0.05
Male sterilization
0.1
0.15
Spermicide
6.0
25.7
Periodic Abstinence
9.0

Calendar
3.0

Ovulation
2.0

Symptothermal
1.0
Post- ovulation
Withdrawal
4.0
23.6
Condom
3.0
13.9

Male
5.0
21.0
Female
Cervical Cap
20.0
40.0

Parous
9.0
20.0
Nulliparous

Failure of contraception because some women just ask neighbors

about what contraceptives they use and how they take it1
Hormone-secreting IUDS have high success rate1
Abstinence (usual method used by many) has very high failure rate1
Failure of withdrawal method: presence of sperm in preejaculate1
Failure of condom: putting condom in wallets, expired condoms1

Figure 1. Contraceptive use effectiveness. Pregnancy rates with perfect

and typical use, by method

THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

Contraceptives which you do not have to remember to take have low

failure rates! 1
Page 1 of 7

GYNECOLOGY 1.4

HORMONAL CONTRACEPTION
Oral Contraceptive Pills
o COC (Combined oral contraceptives)
o POP (Progesterone only pills)
Injectable contraceptives- DMPA
Patch contraceptives- EVRA
Implants- Norplant, Implanon
IUD with Progesterone- Mirena
HORMONAL CONTRACEPTION: A HISTORY
Ludwig Haberlandt (1885- 1932)
Grandfather of the pill
Professor of Physiology at the Medical University of Innsbruck, Austria
In 1919, he implanted the ovaries of a pregnant rabbit under the skin
of a non- pregnant one, making it infertile for several months despite
frequent coitus. He suggested that a substance with similar biological
properties (as the hormone secreted by the corpeus luteum) could be
the basis for a human oral contraceptive.
Late 1920s, he tried to develop the idea of temporary hormonal
contraception, then contradictory to the moral, ethic, religious and
political agendas. Haberlandt wrote: As long certain levels of
progesterone persist in the circulation, hormonal signals favouring the
ripening of additional ovarian follicles, thickening of the endometrium
and release of the ova would not occur.
In 1932, after his death, his tests were dropped and forgotten.
Russell Marker (March 12, 1902- March 23, 1995)
Organic chemist
Pennsylvania State University
In 1939, he discovered that the yam plant, barbaso, abundant in New
Mexico contained high levels of sapogenins, which served as
precursors of steroid hormones. He developed a method of
synthesizing progesterone from these plant compounds.
In 1944, he co-founded SYNTEX and broke the monopoly of European
pharmaceuticals.
Gregory Pincus and Min Chueh Chang
They were reproductive Physiologists
In 1951, they showed that injections of progesterone suppressed
ovulation in rabbits. This ushered the era of oral contraception by
ovulation inhibitors with progesterone.
In 1953, they published the ovulation- inhibiting potency of
progesterone and some of its derivatives administered by several
routes.

Table 4. Different Generations of OCPs.

GENERATION
ETHINYL
ESTRADIOL
First
>50 ug
Second
30-35 ug

20-30 ug

Fourth

20-30 ug

Norethindrone
Levonorgestrel Norgestimate
Cyproterone acetate
Gestodene
Desogestrel
Drospirenone

Table 5. Newer OCP formulations, variation in dose

Monophasic All 21 active pills contain the same amount of estrogen
and progestin
Biphasic
21 active pills contain 2 different estrogen and
progestin combinations (e.g. 10/11)
Triphasic
21 active pills contain 3 different estrogen and
progestin combinations (e.g. 6/5/10)
Table 6. Definitions of the different generations of OCPs
Low
does
oral Products containing <50ug ethinyl estradiol
contraceptives
First- generation
Products containing >50ug ethinyl estradiol
oral contraceptives
Second- generation Products
containing
levonorgestrel,
oral contraceptives
norgestimate, and other members of the
norethindrone family with 20, 30 or 35ug
ethinyl estradiol
Thirdgeneration Products containing desogestrel or gestodene
oral contraceptives
with 20, 30 or 35ug ethinyl estradiol
For table on Combined Oral Contraceptives in the Philippines, please refer
to appendix A
Table 7. Progestin components.
New progestins:
Minimize androgenic effects

Desogestrel
Comparable with previous low- dose products

Gestodene

Contraceptive efficacy

Norgestimate

Breakthrough bleeding

Amenorrhea

Carbohydrate metabolism
Decreased androgenicity

Increase in SHBG

Decreased free testosterone

Margaret Sanger and Katherine McCormick

Became known during the 1960s
Margaret Sanger was the founder of the American Birth Control
Movement. She led the campaign in the US that would gradually -over
decades- desensitize the general public on matters of sex
Katherine McCormick was the financier for the movement, is a
suffragist and a philanthropist. She was dedicated to the birth control
movement because she feared having with her husband due to his
schizophrenia.
EVOLUTION OF THE COMBINED ORAL CONTRACEPTIVE PILLS
Combines OCPs: progesterone and estrogen
Needed very high doses of progesterone to stop ovulation added
ethinyl estradiol

Third

PROGESTOGEN

New progestin:

Drosperinone

THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

Analogue of Spironolactone
Biochemical profile is similar to progesterone

High affinity for the mineralocorticoid

receptor antimineralocorticoid effect

Antiandrogenic activity
Caution is recommended in regard to serum K+
levels

Abnormal renal, adrenal or hepatic

function

ORAL CONTRACEPTIVES
Estrogen
o Ethinyl estradiol
o Mestranol
Progesterone
o Norgestrel and Levonorgestrel: Nordette
o Desogestrel
| Page 2 of 7

GYNECOLOGY 1.4
o
o
o

Norgestimate
Gestodene
Drospirenone

MECHANISM OF ACTION OF OCPs

Hypothalamic Inhibition
o Suppression of hypothalamic gonadotropin- releasing factors
Pituitary Inhibition
o Prevents secretion of FSH and LH

ESTROGEN
Prevents ovulation by suppression of hypothalamic GnRH releasing
factors
Prevents pituitary secretions of FSH and LH
inhibits implantation by altering normal endometrial maturation
Faster ovum transport egg reaches the endometrium before
endometrium is ready to accept it
Used in morning after pills1
PROGESTERONE
Produces thick, scanty, cellular cervical mucus that impairs sperm
transport This is the major action of progesterone
Inhibits sperm capacitation
Endometrium unfavourable to blastocyst implantation
o Because it becomes very thin; considered as the second defense in
the event that there is still fertilization despite contraceptive use1
Inhibits ovulation by suppressing gonadotropins
Does not really act on ovulation except for the newer forms 1
EFFICACY OF ORAL CONTACEPTIVE PILLS

Method
o Start on day 1 of menses
o Do not miss a daily hormonal pill in 21 or 24 days (12- hour
window)
o Strict adherence to 7 or 4 pill- free days critical to obtaining
reliable, effective contraception
o Even if no pills have been missed, patients should be instructed
to use a back- up method for at least 7 days after an episode of
gastroenteritis

Table 8. Drugs that may reduce estrogen and progesterone oral

contraceptive efficacy
INTERACTING DRUG
DOCUMENTATION
Anti-TB
Rifampicin
Established
Antifungal
Griseofulvin
Strongly suspected
Anticonvulsants
Phenytoin
Strong suspected, clinical trial
and sedatives
Mephenytoin
data lacking
Phenobarbital
Primidone
Carbamazepine
Ethosuximide
Antimicrobials o Tetracycline,
o Two small trials found no
NO EFFECT!
doxycycline
association
o Penicillin
o No association
documented
o Ciprofloxacine o No effect on efficacy of a
30 ug EE + DSG OC
o Ofloxacin
o No effect on efficacy of a
30 ug EE + LNG OC

BENEFICIAL EFFECTS OF ORAL CONTACEPTIVE PILLS

Lower incidence of PID
o Because with the use of pills, thick cervical mucus develops so
bacteria cannot penetrate1
Prevents ectopic pregnancy
o Because you prevent ovulation1
Less iron deficiency anemia
o Progesterone leads to thinned endometrium leading to less
volume of endometrial blood1
Less dysmenorrhea
o
Because of the less volume of endometrial blood1
Less PMS
Less endometriosis
o Due to less menstruation1
Decrease incidence of endometrial and epithelial ovarian cancer
o Because the thicker the endometrium, the higher the chance of
endometrial cancer; with progesterone, the endometrium is
thinned so there is protection; epithelial ovarian cancer is related
to the number of ovulations a woman will have in her lifetime, so
with pills, you do not ovulate decreasing the chances of ovarian
cancer1
Decrease incidence of benign breast tumors
Non Contraceptive Benefits:
o Lowered chances of colon CA
o Lowered Acne especially Diane 35
o Decreased Premenstrual Dysphoric Disorder Psych symptoms
happen
COMBINED ORAL CONTRACEPTIVE:
WHO ELIGIBILITY CRITERIA FOR CONTRACEPTIVE USE 2004
Category 1: A condition for which there is no restriction for the use of
the contraception method

Category 2: A condition where the advantages of using the method

outweigh theoretical or proven risks
o Smoking woman < 35 years
o Migraine without aura in a woman aged < 35 years
o DM without complications
o Family history of DVT or pulmonary embolism in first- degree
relatives
o Breastfeeding and 6 months or more post- partum
o History of hypertension during pregnancy
o Uncomplicated vascular heart disease
o Unexplained vaginal bleeding
o Undiagnosed breast mass
o Symptomless gallbladder disease
o Obesity 30 mg/km2 BMI The bigger the patient is, the less
effective the hormones are

Category 3: A condition where the theoretical or proven risks usually

outweigh advantages (Contraindications)
o Smoking up to 15 cigarettes daily in women > 35 years old
o BP systolic 14-159 mmHg/ diastolic of 90-99mmHg
o Hyperlipidemia
o Migraine without aura in women >35years old
o History of breast CA without disease for the last 5 years
o Breastfeeding 6 weeks- 6 months post-partum
o < 21 days post- partum
o Mild cirrhosis
o Symptomatic gallbladder disease
o Drug treatment affecting liver enzymes:

Rifampicin

Anything that has a high liver degradation component would affect

your pills1

THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

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GYNECOLOGY 1.4

Category 4: A condition which represents an unacceptable health risk

if OCP is used
o Breastfeeding <6 weeks post-partum
o Current and history of IHD or stroke
o Smoking >15 cigarettes per day in women 35 years old and above
o BP >160 mmHg/ >100 mmHg
o Migraine with aura
o DM with vascular complications
o Past or present evidence of DVT or pulmonary embolism
o Major surgery with prolonged immobilization
o Thrombogenic mutations
o Complicated valvular heart disease
o Breast cancer within the past 5 years
o Active viral hepatitis, liver tumor and cirrhosis
EFFECTS OF ORAL CONTACEPTION
VENOUS THROMBOEMBOLISM
Venous thromboembolism
o Deep vein thrombosis
o Pulmonary embolism
WHO collaborative study of CV disease and steroid hormone
contraception (Avoid these 2! 1)
o Levonorgestrel vs non- users: O.R. 3.5
o Desogestrel vs non- users: O.R. 9.1
Risk declined with increasing duration of use of OCPs
Risk slightly greater with desogestrel or gestodene use
Smoking > 10 cigarettes per diay increased the risk
OCP w/ 20 ug estrogen had a lower risk than products w/ 30-40 ug
Progesterone Only Pills have no increased risk
ARTERIAL THROMBOSIS
Arterial thrombosis
o Acute myocardial infarction
o Stroke
Smoking produced an additive increase in risk of arterial thrombosis
abut had no effect on risk of venous thromboembolism

ACUTE MYOCARDIAL INFARCTION

Table 9. Transnational case-control study of MI
CASES
CONTROLS
O.R.
Any OC use
57
156
2.35
50 ug
14
22
4.32
estrogen
Old progestin 28
71
2.96
New
7
49
0.82
progestin

Anticonvulsants- Phenytoin, carbamazepine, barbiturates,

primidone, topiramite, oxcarbazepine

C.I.
1.42- 3.89
1.5911.74
1.54- 5.66
0.29- 2.31

88
485

485 women will have MI if they are >/= 35, smoking, and taking OCP1

Combined oral contraceptives and myocardial infarction

WHO multicenter study 2002

368 cases of acute MI

Factors associated with increased risk of MI:

o Smoking
o History of hypertension
o DM
o RHD
o Abnormal blood lipid
o Family history of stroke or MI

Factors not associated with increased risk of MI:

o Duration of use and past use did not affect risk
o Not related to estrogen dose and no influence on type of dose of
progestin

STROKE
Older case-control and cohort studies: Increased risk of cerebral
thrombosis among current users of high-dose oral contraceptives
Thrombotic stroke not increased in healthy, non-smoking women
with <50 ug of estrogen
Risk increased 2x by smoking OCP with 30-40 ug estrogen

BREAST CANCER
Table 11. Breast cancer patients and OCP use.
INVASIVE BREAST CANCER
PRESENT
OCP
3, 497
No OCP use
1,032
Odds Ratio
0.91

THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

ABSENT
3, 658
980
95% CI (0.90- 0.91)

Use of OCP does not lead to an increased risk of breast cancer

MIGRAINE
Table 12. Migraine and OCP use.
IN WOMEN WITH
MIGRAINE
OCP USE
PRESENT
YES
35
NO
256
Odds Ratio
5.46
Chi Square: 37.19

With the new progestin, it is almost protective already as compared

with the older versions1

Table 10. Incidence of myocardial infarction in reproductive aged women

Overall incidence
5 per 100, 000 per year
Women < 35
4

Non- smokers

Non- smokers and OCs 4

8

Smokers
43

Smokers and OCs

Women >35
10

Non- smokers

Non- smokers and OCs 40

Smokers
Smokers and OCs

STROKE
ABSENT
18
718
95% CI (5.15- 5.75)

Women with migraine who use OCP have an increased risk of stroke
(Very significant!) 1
GUIDELINES OF THE FAMILY PLANNING ORGANIZATION OF THE
PHILIPPINES
First 3 weeks postpartum
COCs should not be used during the first 3 weeks post- partum to
avoid the risk of thromboembolic complications
>21 days blood coagulation and fibrinolysis: Normal; COCs can then
be used if mother does not breastfeed
Progesterone only pills can be started at any time after delivery if
mother chooses not to breastfeed
PROGESTERONE ONLY PILLS (POPs)
Contraceptive with progestin only in a smaller dose
| Page 4 of 7

GYNECOLOGY 1.4

They have developed this such that it can already stop ovulation even
if it only contains progesterone1
Preparations available in the Philippines:
o Desogestrel (Cerazette) 75ug
o Lynestrenol (Exulton)
No effect on blood pressure or coagulation factors
Negligible effect on lipid metabolism

GUIDELINES OF THE FAMILY PLANNING ORGANIZATION OF THE

PHILIPPINES: PROGESTERONE ONLY PILLS (POPs)
POPs may be used by women with no contraindications and who are/
have:
o Adolescents
o > 35 years
o With varicose veins
o With sickle cell disease
PROGESTERONE ONLY PILLS (POPs):
WHO ELIGIBILITY CRITERIA FOR CONTRACEPTIVE USE 2004
Category 1: A condition for which there is no restriction for the use of
the contraceptive method
Category 2: A condition where the advantages of using the method
generally outweigh the theoretical or proven risks
Category 3: A condition where the theoretical or proven risks usually
outweigh the advantages of using the method. POPs should not
generally be used in the presence of:
o Current DVT or Pulmonary embolism
o Active viral hepatitis
o Liver tumor
o Severe decompensated cirrhosis
o History of breast cancer and no disease for the last 5 years
o Breastfeeding and <6 weeks postpartum
o Drug treatment affecting liver enzymes: Rifampicin,
anticonvulsants
Category 4: A condition which represents an unacceptable health risk
if the contraceptive method is used. POPs should not be used in the
presence of:
o breast cancer within the past 5 years
INJECTABLE PROGESTERONE HORMONES/ PROGESTINE ONLY
INJECTABLE CONTRACEPTIVES (POIs)
Depot medroxyprogesterone acetate (DMPA) is given every 3 months
Norethisterone ethanate (Noristerat) or NET- EN 200mg given every
2 months, not available in Philippines1
WHO Eligibility Criteria same as POPs
High efficacy and low fail rate since you do not need to take it
everyday1

GUIDELINES FPOP: PROGESTIN ONLY INJECTABLE CONTRACEPTIVES

Lactation
o Hormonal methods are not the method of choice for
breastfeeding women
o Should not be started before the 6th week postpartum by women
who are fully or nearly fully breastfeeding

Adolescents
o Hypo-estrogenic effect and possible changes in bone mass
density
o With risk factors for osteoporosis (e.g. Steroids- it should not be
given; a COC may be the more suitable alternative)

EVIDENCE OF DMPA AND BREAST CANCER

Table 13. Breast cancer and DMPA
OUTCOME
TYPICAL OR (95%
p- value
CI)
Breast cancer (Overall)
1.1 (1.97, 1.4)
Not significant
Breast cancer (According 1.1 (.197, 1,4)
Not significant
to duration of use, age)

MECHANISM OF ACTION
Ovulation inhibition, unlike the older versions, this is a very good
inhibitor1
Increase cervical mucus viscosity
Endometrium unfavorable for implantation

BENEFITS OF INJECTABLE PROGESTERONE

Tricglycerides and HDL decreased
No increase in LDL
Decreased iron deficiency anemia They do not menstruate
Decreased endometrial and epithelial ovarian cancer

DISADVANTAGES
Prolonged amenorrhea
Prolonged spotting/ bleeding, they may have this everyday1

Prolonged anovulation after discontinuation

Return of fertility delayed, upto several months after.1
o This is unlike OCP, where return of fertility is immediate.1
Depression
Breast cancer
Cervical cancer
o The reports about this are not very convincing. 1
Osteoporosis
o We ask them to take Calcium for the 3 months they are on DMPA1

THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

PROGESTERONE IMPLANTS
Implanon
Inserted subcutaneously under local anesthesia
Implanon side effects
o Irregular bleeding
o Pain and scarring on site
o May not be as effective in obese or overweight women
o Headache, weight gain, depression, acne
Free in government hospital. Training on how to insert this is a must
prior to its administration.1
May not be as effective in obese and overweight women. 1
Effect is same as other progesterone. 1
MECHANICAL CONTRACEPTION
DIAPHRAGM
Latex cup with a spring mechanism in its rim to anchor it in the vaginal
canal
Diagonal length of the vaginal canal determines correct diaphragm
size
Posterior rim should fit into posterior fornix and anterior rim is
behind the pubic bone
Spermicidal cream or jelly applied to inside of the dome
Contraception lasts for 6 hours
SPERMICIDES
Consists of a base combined with nonoxynol- 9 oxtocynol
Destroys the sperm cell membrane
Inserted into the vagina prior to each coitus
Prevent sperm from entering the cervical os by attacking the sperms
flagella and body reducing their mobility and disrupting their
fructolytic activity
Diaphragm and spermicides must be used together. 1
Spermicides have high failure rate if used alone. 1
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GYNECOLOGY 1.4
SPREMICIDES: CREAMS, JELLIES, SUPPOSITORIES, FILMS AND FOAM
Highly spermicidal
For women who need temporary protection
Must be deposited high in the vagina in contact with cervix before
intercourse

Duration of maximal spermicidal effectiveness: 1 hour

Cu- 7
TCu- 200
TCu- 380A
Lng IUD

BARRIER CONTRACEPTION
The condom remains the only contraceptive method that offers an
overall decreased risk of acquiring and transmitting STIs
CONDOMS
Read the label
FDA approval
Expiration date should be checked
Type of condom: Latex, polyurethane
Condoms for males and females are available (but vaginal condoms
are not available here in the Philippines) 1
There are a lot of failure rates since people do not know how to use it
properly. 1
INTRAUTERINE DEVICE
Chemically inert: Non- absorbable material, most often polyethylene
and impregnated with barium sulphate Chemically active: Continuous
release of copper or progestational agents
Chemically inert IUD do not have an effect in ovulation. Thus, SOME
studies show that this has an increased risk of ectopic pregnancy. The
fertilize egg cannot implant inside the uterus, and will implant
somewhere else.1
MECHANISM OF ACTION
Interferes with implantation of fertilized ovum
Intense inflammatory response which is induced by copper containing
deviceslysosomal activation and other inflammatory actions which
are spermicidal
Accelerate motility
Atrophic endometrium
o Levonorgestrel (LNG) containing: Ovulation inhibition, thinned
endometrium, thick cervical mucus

ELIGIBILITY CRITERIA: IUD IS NOT RECOMMENDED IN THE FOLLOWING

Women with multiple sexual partners or whose partners have multiple
sexual partners (Increased risk of infections) 1

Who are drug or alcohol dependent

Current or previous history of PID

Women with abnormalities of uterine anatomy

Immunosuppressed patients, due to increased risk of infection1

CONTRAINDICATIONS
Suspicion of pregnancy
Abnormality of uterus with distorted cavity
History of PID
Postpartum endometritis, infected abortion
Genital bleeding
Allergy to copper
Patient or partner with multiple sex partners

EFFECTIVENESS OF IUD
Table 14. Effectiveness of IUD.
DEVICE
PREGNANCY
EXPULSION
RATE %
RATE %
Lippes Loop
3
12-20

REMOVAL
RATE %
12-15

6
8
14
6

11
11
14
17

IUD AND ECTOPIC PREGNANCY

Table 15. Ectopic pregnancy and IUD.
ECTOPIC PREGNANCY
1000 WOMEN
Non- contraceptive users, all ages 3.0-4.5
Levongorggestrel IUD
0.20
TcU-380 IUD
0.20

2-3
3
0.5-0.85
0.2

RATES/

Use of Levonorgestrel containing IUD does not increase the risk of

ectopic pregnancy
IUD users are 50% less likely to have ectopic pregnancy when
compared with women using no contraception
TIMING OF INSERTION
IUD may be inserted at any time after delivery or spontaneous
abortion or during the menstrual cycle
Should not be inserted if with intrauterine infection
Insertion immediately postpartum: Higher expulsion rate vs insertion
4-8 weeks after delivery
Easier to insert shortly after a menstrual cycle however risk of an
unintended pregnancy is higher
PROPHYLACTIC ANTIBIOTICS AND IUD INSERTION
Doxycycline 200mg 1 hour prior to insertion
Three double blind randomized studies found no significant
advantage in the treated group; Level of Evidence 1b
Women with low risk for STI there is little benefit in giving
prophylactic antibiotics
STERILIZATION
TUBAL LIGATION
Minilaparotomy with pomeroy tubal ligation is the most frequent
method of female sterilization
Safe, simple and adaptable in ambulatory settings
Laparoscopic sterilization
o Occlusion and partial resection by unipolar electrosurgery
o Occlusion and transection by unipolar electrosurgery
o Occlusion by bipolar electrocoagulation
o Occlusion by silastic rings
TUBAL LIGATION AND ECTOPIC PREGNANCY
Tubal ligation: Increased incidence of ectopic pregnancy
Bipolar coagulation via laparoscopy (17.1 per 1000 procedures)
highest 10 year probability
Post- partum partial salpingectomy (1.5 per 1000 procedures)
lowest probability

EVIDENCE OF TUBAL LIGATION AND ECTOPIC PREGNANCY

Table 16. Tubal ligation and Ectopic pregnancy
ECTOPIC PREGNANCY
METHOD OF
PRESENT
ABSENT
STERILIZATION
Bipolar Coagulation
24
2,243
Other methods
23
8,395
Odds Ratio
3.91
95% CI
(3.84- 3.97)

most common1
THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

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GYNECOLOGY 1.4

STERILIZATION AND OVARIAN CANCER

Tubal sterilization associated with 67% reduced risk of ovarian
cancer
30% reduction in risk of fatal ovarian cancer

TUBAL LIGATION AND MENSTRUAL FUNCTION

Table 17. Menstrual function and Tubal ligation.
O.R.
C.I.
Decrease in menstrual 1.3
Not significant (1.0-1.8)
pain
Increase
in
cycle 1.3
Not significant (1.0-1.8)
irregularity

N= 9, 514 ligated women from 1978- 1987

Slight decrease in days of bleeding: O.R. is 2.4 (1.1- 5.2)
Decrease in the amount of menstrual bleeding O.R. is 1.5 (1.1-2.0)

TUBAL LIGATION AND SEXUALITY

There is no detrimental effect on sexuality
Increased sexual interest and pleasure about 10-20%
Negative effects would occur in less than 4% (Post- sterilization
regret)

o
o

REVERSIBILITY OF TUBAL LIGATION

They say that this is permanent but nothing is really permanent these
days. You can actually reverse tubal ligation.1
2% of women expressed regret 1 year later
2.7% after 2 years
Main factors associated with regret
o Age less than 30-early age1

Sterilization at the convenient time of CS delivery

In Europe, most important risk factor for regret was an unstable
marriage
1995 National Survey of Family Growth
o 25% of US women expressed desire for reversal by either one of
the partners or both
VASECTOMY
Vas deferens from each testicle is clamped, cut or sealed which
prevents sperm from mixing with the semen
Sterilization is achieved after 20-30 ejaculations
Semen analysed after 2 negative counts to be labeled sterile
3 months post-surgery semen analysis
Failure rate: 9.4%
Fertility restoration is dependent on the interval from the first
surgery
Vasectomy is safer, easier to perform, less expensive (3x) and has a
lower failure rate than female sterilization (10-37x)
Initial cohort showed an increased rate of prostate cancer
Reviews of 6 cohorts and 15 case control
o No increased risk of cancer of the testes after vasectomy
o No increased risk of prostate cancer
VASECTOMY AND SEXUAL SATISFACTION
Vasectomy has no effect on sexual satisfaction, frequency of sexual
intercourse and marital satisfaction who underwent vasectomy

Editor: aia

APPENDIX
APPENDIX A. Combined Oral Contraceptives in the Philippines.

GENERATION
First Generation
Second Generation

Third Generation

Newer Generation

BRAND
Femenal
Nordiol
Lady, Logynon
Diane, Althea
Micropill
Gracial
Mercilon
Gynera
Meliane
Yasmin
YAZ

ETHINYL
ESTRADIOL
50g
50g
35g
35g
35g
40g
20g
35g
20g
30g
20g

PROGESTERONE
Norgestrel
Levonorgestrel
Levonorgestrel
Cyproterone
Norethisterone
Desogestrel
Desogestrel
Gestodene
Gestodene
Drospirenone
Drospirenone

PREPARATION,
START
21/7, day 5
21/7, day 5
21/7, day 1
21/7, day 1
21/7, day 5
22/6, day 1
21/7, day 1
21/7, day 1
21/7, day 1
21/7, day 1
24/4 day 1

Diane 35 is anti-testosterone bigger breasts, better skin

Yazmin advertised that it would produce lower rates of strokes and MI in women who are borderline hypertensive but rates of MI and venous thromboembolism
did not decrease. 1

THE MERMEN | MENDOZA, C. | MENDOZA, G. | MENDOZA, J. | MERCADO, L. | MERILLENO, A.

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