CONTRACEPTIVES

&
FAMILY WELFARE
 Learning Objectives
• Classification

• Mechanism of action
CONTRACEPTIVES
• Routes of Administration

• Adverse Effects

• Indication & Contra-indication

 CONTRACEPTION
• Interception in the birth process at any stage ranging from ovulation to ovum
implantation

• Ideal contraceptive agent –

a) Safe

b) Reversible suppression of fertility

ORAL CONTRACEPTIVES

TYPES
INJECTABLE CONTRACEPTIVES

RECENT CONTRACEPTIVE METHODS

HORMONAL CONTRACEPTION IN MALES

 ORAL CONTRACEPTIVES
• COMBINATION PILLS : Estrogen + Progesterone
( varying amounts or in phased regimens)

MONOPHASIC BIPHASIC TRIPHASIC

• MINI PILLS (PROGESTIN-ONLY PILLS)

• POST-COITAL (Morning pills) PILLS : Emergency contraceptive pill

• CENTCHROMAN : Non-hormonal estrogen receptor antagonist

 COMBINATION PILLS
• Most popular & effective method

• Success rate – 99-99.5%

• Balanced formulation with low doses

of estrogens and progestins
MONOPHASIC PILLS
• No phasic increase or decrease in estrogen/ progestin content

• 1st pill - 5th day after the start of menses

Consecutively for 21 days
Pill free period (7 days)

ESTROGEN Anovulatory cycle

PROGESTERONE Regular cyclic menstrual withdrawal bleed

 What if the patients forgets?
• If the woman misses one pill some day

-She should take 2 pills next day and then continue one pill a day as usual

• If pills have been missed for 2-3 days or at frequent days,

- Course should be stopped

- Mechanical barriers likes condoms, diaphragms or jelly should be used

 BIPHASIC PILLS

• Fixed dose of estrogen for 21 days but with

• Increasing doses of progesterone during two successive phases

• 7 pill free days

• Ethinyl estradiol 35 mcg + Norethindrone 0.5 mg (First 10 days)

• Ethinyl estradiol 35mcg + Norethindrone 1 mg (From day 11 to day 21)

 TRIPHASIC PILLS

• Provides higher dose of estrogen near mid-cycle

• Increase doses of progesterone for 3 successive phases

• 7 pill free days

• Ethinyl estradiol 30mcg + Norgestrel 0.05mg (6 tablet from day 1 to 6)

• Ethinyl estradiol 40 mcg + Norgestrel 0.075 mg (5 tablet from day 7 to 11)

• Ethinyl estradiol 30 mcg+ Norgestrel 0.125 mg (10 tablets from day 12 to 21)
 MECHANISM OF ACTION

• Suppress the ovulation by inhibiting the release of FSH and LH

• High doses of estrogen inhibit LH surge

• Progesterone ensures withdrawal bleeding after stopping the medication

• Disruption the proliferative and secretory phases of endometrium

• Progestogenic effects increase the viscosity of the cervical mucus

 SIDE EFFECTS
ESTROGENIC PROGESTOGENIC
MILD • Nausea • Increase in appetite
• Migraine • Weight gain
• Breast tenderness • Acne
• Mild oedema • Hirsutism
• Withdrawal bleeding • Decrease in libido
• Increase in body temperature

MODERATE • Vertigo • Breakthrough bleeding

• Leg and uterine cramps • Monilial vaginitis
• Precipitation of diabetes • Amenorrhea

SEVERE Mainly estrogenic effects which includes thromboembolism,

cholestatic jaundice, cholelithiasis and hepatic adenoma
MI and cerebro-thrombosis, Risk of cancer
 CONTRAINDICATIONS
Thrombophlebitis, Thromboembolic phenomena,
Cardiovascular,Cerebrovascular disorders

Pregnancy , Undiagnosed vaginal bleeding

Adolescents ( epiphysis closure not completed)

 CAUTION

• Known or suspected tumors of breast or other estrogen-dependent neoplasms

• Heart failure

• Co-administration of antimicrobial drugs

• Patients with – Liver disease

- Migraine

- Convulsive disorders
 MINIPILLS (Progestin-only pills)

• Success rate – 98.3%

• Given to those cases where estrogens are contraindicated.

• Pills prescribed soon after delivery

• Continued without interruption

• Eg;- Norethindrone – 350mcg

Norgestrel - 75mcg
 MINIPILLS
 Mechanism of action -

• Progestin places the endometrium prematurely into the secretory phase

• Increases the viscosity of cervical mucous

 Side effects –
- Acne
- Hirsutism
- Amenorrhea
 Post coital “Morning after pills”
• Emergency contraception pill

• Pregnancy avoided following coitus –

- Estrogen alone
- Progesterone alone
- Combination

• Treatment begun within 72 hrs ; effective -99%

• Administered with anti-emetic – 40% pts have nausea/vomiting

A) Two tablets of the progestin levonorgestrel (0.75 mg each)
• 1st tablet - As soon as possible (within 48hr) & 2nd tablet- after 12hrs

• Alternatively 1.5 mg (As a single tab) can be taken once within 48 hours of the
unprotected coitus

B) Ethinyl estradiol (50 mcg each tablet) + Levonorgestrel (250 mcg)

• Two such tablets are to be taken within 72 hours of the unprotected coitus

• Then next 2 tablets after 12 hours

C) Mifepristone 600mg single dose
• Taken within 72 hours of unprotected coitus

• Antagonist at progesterone & glucocorticoid receptor

• Luteolytic effect

• Combined with prostaglandin – Effective abortifacient

• Mifepristone – 600mg once + Misopostol – 400 mcg once

D) Ulipristal (a single dose of 30 mg)
• Selective Progesterone receptor Modulator (SPRM)

• Taken within 120 hours/ 5 days after an unprotected coitus

• Embryotoxic in animal studies ; pregnancy must be excluded

• S/E – Abdominal pain

 CENTCHROMAN (Ormeloxifene)

• Nonsteroidal estrogen antagonist or SERM

• Developed in India – “SAHELI”

• 30mg of centchroman in each tablet.

• Centchroman is taken

• twice in a week for the first 3 months

• once a week subsequently

 INJECTABLE CONTRACEPTIVES
• Depot medroxyprogesterone acetate (DMPA; Depot Provera)
• Longer acting progesterone derivative

• Injected intra-muscular

• Dose- 150 mg every third month - from parturition

- first 5 days of the menstrual cycle.

• MoA same as mini pills

 Useful in patients where-

• Poor compliance

• Patients having heavy menstrual bleeding or those for whom estrogen is contraindicated

 Side effects-

• Amenorrhea and Anovulation

• Osteoporosis may occur on prolonged used as GN suppression may cause low estrogen
levels.

• Weight gain

• Breast cancer
 COMBINED INJECTABLE CONTRACEPTIVES

• Estradiol valerate 5mg + 17-Hydroxy progesterone caproate - 250 mg IM every

month

• Estradiol cypionate 5 mg + DMPA 25 mg IM, once in 2 months.

• MoA & S/E – same as combination pills

• Advantage – single defined & predictable bleeding every month

 RECENT CONTRACEPTIVE METHODS

NORPLANT
• Set of 6 capsules - each with 36mg of levonorgestrel

• Subcutaneous implantation on the inside of the upper arm

• Effective for up to 5 years

• Contraception-readily reversible with the removal of implants

 INTRAUTERINE INSERTS

• Relatively New intra-uterine contraceptive device

• Releases levonorgestrel-20mcg per day into the uterine cavity for a period of 5
years

• Progestin preparation- acts locally on endometrium

• Side effects are minimal

• Return of fertility is immediate on removal

 Hormonal contraception for men

• Initial dose of 1000 mg IM of testosterone undecanoate followed by 500 mg

maintenance after every 6 weeks produce reversible azoospermia

• Azoospermia within 3 months

• Minimum side effects

 GOSSYPOL
• Oral ; Non steroidal drug –cotton seed

• Dose – 20mg/day for initial 2-3 months

- 60 mg /week – maintenance dose

Not more than 2 years at a stretch.

• Decreases the sperm counts and reduces sperm motility drastically within 3
months.
 GOSSYPOL

• Mechanism of action is not clearly defined - Destroys elements of seminiferous

epithelium

• Recovery is restored several months after discontinuation.

• S/E: Hypokalemia with muscle weakness and transient paralysis

• Diarrhea and breathlessness may occur but libido is not affected

THANK YOU