---

Contraception - Comprehensive MBBS Notes (Theory + Practical)

Sources: Park's Textbook of Preventive & Social Medicine | Ganong's Review of Medical Physiology (26e) | Textbook of Family Medicine (9e) | Goldman-Cecil Medicine | Harriet Lane Handbook | Berek & Novak's Gynecology

---

1. DEFINITION AND OVERVIEW

• 100% effective
• Reversible
• Free of side effects
• Independent of coitus
• Cheap, acceptable, easy to use
• No need for medical supervision
• Does not affect libido or sexual pleasure

---

2. CLASSIFICATION OF CONTRACEPTIVE METHODS

A. By Mechanism

B. By Duration

• Temporary: Barrier, hormonal pills, injectables, IUCDs (reversible)
• Permanent (Terminal): Tubectomy, vasectomy

C. By Timing of Use

• Coitus-dependent: Condoms, diaphragm, spermicides, withdrawal
• Ongoing (coitus-independent): OCPs, IUDs, implants, injectables
• Post-coital (emergency): Emergency contraceptive pills, copper IUD

---

3. EVALUATING CONTRACEPTIVE EFFICACY - PEARL INDEX

Failure rate per HWY = (Total accidental pregnancies / Total months of exposure) × 1200

• The factor 1200 = number of months in 100 years
• Every known conception is included (live births, stillbirths, abortions)
• Deduct 10 months for full-term pregnancy, 4 months for abortion from denominator
• Minimum 600 months of exposure needed for valid conclusions

Failure Rates (Ganong's Table 22-4):

---

4. BARRIER METHODS

A. Male Condom

• Most widely used barrier method; also protects against STIs/HIV
• Failure rate: ~3.6/HWY (typical use)
• Only method that protects against both pregnancy AND STIs
• Latex or polyurethane; non-latex available for latex allergy

B. Female Condom

• Polyurethane sheath inserted into vagina before intercourse
• Less effective than male condom but female-controlled

C. Diaphragm

• Dome-shaped rubber cap covering the cervix
• Must be used with spermicide (nonoxynol-9)
• Inserted before intercourse, left in place 6 hours after
• Requires fitting by healthcare provider
• Failure rate: ~12% (typical use)
• Inappropriate for adolescents (requires foreseeing intercourse)

D. Cervical Cap (FemCap)

• Non-latex cervical cap, comes in 3 sizes
• Associated with 2x higher pregnancy rate compared to diaphragm
• Used with spermicide
• Failure rate: ~17% (typical use)

E. Spermicides

• Contain nonoxynol-9
• Available as gels, foams, creams, films
• Do NOT protect against STIs (important exam point)
• Failure rate: ~11.9/HWY
• Not costly but poor standalone efficacy

---

5. HORMONAL CONTRACEPTION

A. Combined Oral Contraceptive Pills (COCPs)

1. Suppression of ovulation - estrogen + progestin suppress FSH and LH secretion (suppress the midcycle LH surge); multiple irregular LH bursts replace the midcycle peak
2. Cervical mucus thickening - progestin makes mucus thick, viscid, hostile to sperm migration
3. Endometrial changes - progestin causes endometrial atrophy unfavorable to implantation

• Ethinyl estradiol - orally active; has ethinyl group at position 17 of steroid nucleus (resistant to hepatic first-pass metabolism)
• Norethindrone - also has ethinyl group at C17; partly metabolized to ethinyl estradiol → has both progestogenic AND estrogenic activity

• 21 active pills then 5-7 day withdrawal (pill-free interval) → menstrual flow occurs
• Some packs include 28 pills (21 active + 7 placebo)

• ABCDEFGH mnemonic:
  • Active DVT/PE or history of VTE
  • Breast cancer (current)
  • Cerebrovascular disease, CAD
  • Diabetes with vascular complications
  • Epilepsy (on enzyme-inducing drugs)
  • Focal migraine with aura
  • Gallbladder disease (active)
  • Hypertension (BP >160/100), hepatic disease, history of stroke
  • Also: Age >35 + smoking >15 cigarettes/day, postpartum <6 weeks breastfeeding

• Regulates menstrual cycle, reduces dysmenorrhea
• Reduces risk of ovarian and endometrial cancer
• Treats endometriosis, PCOS, acne, hirsutism
• Reduces iron-deficiency anemia
• Reduces fibrocystic breast disease, PID risk

• Nausea, breast tenderness, breakthrough bleeding, headache (estrogen-related)
• Weight gain, depression, decreased libido (progestin-related)
• VTE risk (especially 3rd/4th generation progestins - desogestrel, gestodene, drospirenone)
• Hypertension, stroke risk in smokers >35

• Monophasic: Same dose each day (most common)
• Biphasic: Dose changes once mid-cycle
• Triphasic: Dose changes 3 times, mimics natural cycle
• Extended-cycle/continuous: 84 active + 7 placebo (e.g., Seasonique) - only 4 periods/year

---

B. Progestin-Only Pills (Mini-Pill)

• Contains only progestin (no estrogen)
• Mechanism: Thickens cervical mucus, endometrial atrophy; less reliable ovulation suppression
• Indications: Women who cannot take estrogen - breastfeeding mothers, hypertension, VTE risk, >35 with smoking
• Key rule: Must be taken at same time every day (no >3-hour window)
• Creates estrogen-deficiency state → early cycle bleeding or continuous bleeding throughout the cycle
• Failure rate: ~1.2/HWY

---

C. Injectable Contraceptives (Depo-Provera)

• DMPA (Depot Medroxyprogesterone Acetate): 150 mg IM every 13 weeks (3 months)
• Progestin-only; suppresses ovulation
• Advantages: No daily compliance, highly effective, reduces sickle cell crises
• Disadvantages: Irregular bleeding, amenorrhea, weight gain, delayed return of fertility (up to 12-18 months), decreased bone mineral density with prolonged use
• Timing: Give within first 5 days of cycle OR within 5 days postpartum if not breastfeeding

---

D. Subdermal Implants (Implanon/Nexplanon)

• Etonogestrel-releasing rod inserted under skin of upper arm
• Effective for up to 3 years (levonorgestrel implants up to 5 years)
• Mechanism: suppresses ovulation + thickens cervical mucus
• Highly effective (failure rate <0.1/HWY)
• Irregular bleeding is the most common complaint
• Requires trained provider for insertion/removal

---

E. Hormonal Patch and Vaginal Ring

• Ortho-Evra patch: Transdermal; changed weekly for 3 weeks then 1 patch-free week; contains ethinyl estradiol + norelgestromin; 420 mcg EE per 28-day cycle
• NuvaRing: Flexible plastic ring inserted intravaginally for 3 weeks, removed for 1 week; lowest EE content (315 mcg per 28-day cycle); contains etonogestrel (3rd-generation progestin)
• Both 3rd-generation progestins associated with increased VTE risk (Family Medicine, 9e)

---

6. INTRAUTERINE DEVICES (IUDs/IUCDs)

Mechanism of Action

• Foreign body causes sterile inflammatory reaction in uterus, toxic to sperm
• Inhibition of sperm motility
• Reduced sperm capacitation and survival
• Sperm phagocytosis by macrophages
• Copper ions exert additional spermatocidal effect
• LNG-IUS additionally thickens cervical mucus

Types of IUDs

Complications of IUD

• Infection (mainly in first month post-insertion; higher risk with STIs)
• Uterine perforation during insertion
• Expulsion (more common in young nulliparous women)
• Menorrhagia and dysmenorrhea (copper IUD)
• Ectopic pregnancy risk if method fails
• PID (especially if multiple partners)

Contraindications to IUD

• Current PID or STI
• Uterine anomaly (bicornuate, septate uterus)
• Unexplained vaginal bleeding
• Known or suspected pregnancy
• After molar pregnancy: wait until hCG normalizes (risk of perforation, bleeding, infection) - (Berek & Novak's)
• Copper allergy (for CuT)

IUD Insertion Timing

• Ideal: Day 1-5 of menstrual cycle (ensures not pregnant)
• Immediately postpartum (within 48 hours) or after 4-6 weeks
• Immediately post-abortion

---

7. NATURAL/BEHAVIORAL METHODS

A. Rhythm Method (Calendar/Ogino-Knaus Method)

• Based on calculating fertile period from last 6-12 months of cycle lengths
• Fertile period = Shortest cycle - 18 days to Longest cycle - 11 days
• Ovulation = Day 14 (in 28-day cycle); egg survives 12-24 hours; sperm viable 48-72 hours
• Abstain during calculated fertile window
• Failure rate: ~15.5/HWY - highest among standard methods

B. Basal Body Temperature (BBT) Method

• Slight fall (~0.2°C) just before ovulation; then sustained rise of 0.2-0.5°C post-ovulation (due to progesterone)
• Abstain from menstruation until 3 days after sustained temperature rise
• Limitation: Can only confirm ovulation has occurred (retrospective); many factors affect BBT

C. Cervical Mucus Method (Billings/Ovulation Method)

• At ovulation: mucus is clear, copious, slippery, stretchy (spinnbarkeit), like raw egg-white
• Post-ovulation: mucus becomes thick, scant, cloudy (due to progesterone)
• Abstain when any mucus is present until 4th day after peak mucus

D. Symptothermal Method

• Combines BBT + cervical mucus + calendar - more effective than any single natural method

E. Standard Days Method

• Based on fixed fertile window: Days 8-19 of cycle (for women with cycles 26-32 days)
• Use CycleBeads (color-coded beads) as reminder

F. Lactational Amenorrhea Method (LAM)

• Highly effective temporary method if ALL 3 conditions met:
  1. Baby is <6 months old
  2. Exclusively breastfeeding (no supplemental feeds, no intervals >4-6 hours)
  3. Mother is amenorrheic (no menstrual bleeding since delivery)
• Mechanism: frequent suckling suppresses GnRH → no LH surge → no ovulation
• Failure rate: <2% if all 3 criteria met; must switch to another method if any criterion broken

G. Coitus Interruptus (Withdrawal)

• Male withdraws before ejaculation
• Failure rate: ~6.7/HWY
• Requires high motivation and self-control; pre-ejaculate fluid may contain sperm
• No STI protection

---

8. EMERGENCY CONTRACEPTION (EC)

Types and Timing

Mechanism of Emergency Contraception

• LNG pills: Primarily delay or inhibit ovulation; does NOT interrupt established pregnancy
• UPA: Selective progesterone receptor modulator; also delays ovulation
• Copper IUD: Spermicidal; prevents fertilization; can also inhibit implantation if fertilization occurred

Key Exam Points

• Copper IUD is the most effective EC but requires provider insertion
• LNG EC is available over-the-counter for women ≥17 years (in US)
• EC does NOT terminate established pregnancy (not an abortifacient when used within 72 hours)
• 9x more women use oral EC than copper IUD despite IUD's superior efficacy

---

9. PERMANENT METHODS (STERILIZATION)

A. Female Sterilization (Tubectomy)

• Pomeroy technique (most common) - loop of tube ligated and cut; ends separated by fibrosis
• Parkland method - segment excised, ends buried in broad ligament
• Irving method - tube buried in uterine musculature (lowest failure rate)
• Uchida method - submucous injection of saline + adrenaline, tube excised
• Hulka/Falope rings - applied laparoscopically (Falope ring = silastic band)
• Filshie clip - titanium clip; best reversal rates
• Essure - hysteroscopic permanent sterilization (no longer available in many countries)

• Laparoscopy - most common; CO2 insufflation; shorter hospital stay; small scar; NOT suitable postpartum for 6 weeks (but CAN be done concurrent with MTP); Hb must be ≥8 g/dL
• Minilaparotomy (Minilap) - 2.5-3 cm incision under local anesthesia; suitable for postpartum sterilization; can be done at PHC level; revolutionary for mass campaigns

• Interval: 6+ weeks after delivery
• Postpartum: Within 48 hours of delivery (Minilap preferred)
• Concurrent with MTP/cesarean section

B. Male Sterilization (Vasectomy)

• Conventional vasectomy: Small scrotal incision; vas deferens identified, segment excised or ligated
• No-Scalpel Vasectomy (NSV): New technique; puncture only (no incision); safer, more acceptable; less bleeding/infection; promoted under family welfare programme with UNFPA funding

1. Not immediately sterile - need at least 30 ejaculations before semen is sperm-free
2. Use contraception until aspermia confirmed on semen analysis
3. No bath for 24 hours
4. Wear scrotal support (T-bandage) for 15 days
5. Avoid cycling/heavy lifting for 15 days; no complete bed rest needed
6. Suture removal on 5th day

---

10. WHO MEDICAL ELIGIBILITY CRITERIA (MEC)

Selected Important MEC Conditions

---

11. CONTRACEPTION IN SPECIAL SITUATIONS

Postpartum

• Breastfeeding: Progestin-only methods preferred; COCPs avoided <6 months (reduce milk supply); LAM effective if all 3 criteria met
• Non-breastfeeding: Combined OCPs can start 3-4 weeks postpartum
• Copper IUD: Can insert immediately postpartum (within 48 hours) or after 4 weeks

Adolescents

• Hormonal methods most suitable (reversible, do not affect future fertility)
• Condoms for dual protection (pregnancy + STI)
• IUDs theoretically contraindicated (PID risk) but better than repeated illegal abortions
• Diaphragm/cervical cap - inappropriate (require forethought)
• Rhythm method - unreliable (irregular cycles common in adolescents)

Perimenopausal Women

• Can still get pregnant until 12 months of amenorrhea confirmed
• COCPs carry higher death risk in women >40 regardless of tobacco use
• Non-hormonal or LNG-IUS preferred

After Molar Pregnancy (Berek & Novak's)

• Use contraception during entire hCG surveillance period
• IUDs contraindicated until hCG normalizes (risk of perforation, bleeding, infection)
• Oral contraceptives safe after molar evacuation; do NOT increase risk of postmolar GTD

---

12. FAMILY PLANNING IN INDIA (PSM - Exam Essential)

National Family Welfare Programme

• Centrally sponsored scheme; 100% central funding
• Emphasis on 2-child family; voluntary informed acceptance
• Two major recent changes: (1) Greater emphasis on spacing methods alongside terminal methods; (2) Take services to every doorstep

Terminology Change

• "Family Planning Programme" renamed "Family Welfare Programme" in 1977 (to remove coercive connotations)

National Population Policy 2000

• Immediate objective: Address unmet needs for contraception
• Medium-term: Bring TFR to replacement level (2.1) by 2010
• Long-term: Achieve stable population by 2045

Contraceptive Acceptors - MBBS viva points

• Target Free Approach (TFA): Introduced 1996 - no numeric targets for sterilization; replaced Community Needs Assessment Approach (CNAA) in 1998
• RCH Programme (Reproductive and Child Health): Integrated approach post-1997

---

13. PRACTICAL EXAM TIPS

How to Counsel a Patient Choosing Contraception (OSCE Approach)

1. Ask about age, parity, desire for future pregnancy
2. Assess medical history (HTN, diabetes, VTE, migraines, cardiac disease, liver disease)
3. Assess smoking status and age
4. Ask about breastfeeding status if postpartum
5. Assess STI risk (number of partners)
6. Explain available methods with efficacy, mechanism, side effects
7. Address non-contraceptive benefits (important for compliance)
8. Discuss warning signs (ACHES for COCPs: Abdominal pain, Chest pain, Headaches, Eye changes, Severe leg pain)

ACHES Mnemonic for OCP Danger Signs (Practical)

• A - Abdominal pain (DVT mesenteric vessels, hepatic adenoma)
• C - Chest pain (PE, MI)
• H - Headaches (cerebrovascular accident)
• E - Eye changes, blurred vision (retinal artery thrombosis)
• S - Severe leg pain (DVT)

Instruments to Identify (Practical Exam)

• Copper-T 380A: T-shaped IUCD with copper wire wound around stem
• Lippes Loop: Discontinued but may appear in exams; double-S shaped plastic
• Falope Ring: Silastic band for laparoscopic tubectomy
• Diaphragm: Dome-shaped rubber cap; shown with spermicide tube
• Implant rod (Implanon/Nexplanon): Single matchstick-sized rod

---

14. HIGH-YIELD EXAM SUMMARY TABLE

---

15. QUICK MEMORIZATION AIDS

• Perforation (uterine)
• Infection (PID)
• Expulsion

• Oral: COCPs, POPs
• Injection: DMPA (3-monthly), Net-EN (2-monthly)
• Implant: Under skin (3-5 years)
• Intrauterine: LNG-IUS (5 years)
• Transdermal: Patch (weekly)
• Vaginal: Ring (monthly)

---