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Methods of Contraception — Study Notes

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1. Family Planning (WHO Definition)

• Prevention of unwanted pregnancies
• Achieving the desired number of children
• Regulating intervals between pregnancies
• Selecting timing of birth relative to parental age

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2. Overview of Methods

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3. Combined Oral Contraceptives (COCs)

Composition & Types

• Monophasic: 21 active pills with equal estrogen + progestogen throughout
• Biphasic: Constant estrogen; progestogen increases in Phase 2
• Triphasic: Three-step escalation of both hormones; estrogen rises in Phase 2; progestogen rises in three stages

Dosage Classification (by ethinyl estradiol content)

Mechanism of Action

1. Suppresses ovulation — combined estrogen + progestin suppress FSH and LH (eliminates the midcycle LH peak). High-dose estrogen alone depresses FSH; combined pill suppresses both gonadotropins
2. Endometrial changes — rapid secretory transformation → atrophic changes → hostile to implantation
3. Cervical mucus thickening — progestin makes mucus thick and impenetrable to sperm
4. Reduced tubal peristalsis — slows egg transport

Effectiveness

• 0.3 pregnancies per 100 women/year with perfect use

Absolute Contraindications

• Pregnancy / lactation
• Unexplained vaginal bleeding
• Active heart disease
• Thromboembolic disease, thrombophlebitis, CVA, or MI (current or history)
• Thrombophilic mutations (clotting disorders)
• Migraine with neurological symptoms (aura)
• Age >35 + smoking
• Arterial hypertension
• Diabetes mellitus
• Breast cancer
• Acute liver disease
• Major surgery with prolonged immobilization

Disadvantages

• Must be taken daily (non-adherence reduces efficacy significantly)
• Does not protect against STIs
• May delay return of fertility in ~1–2% of users
• Rare but serious: MI, stroke, pulmonary embolism — risk elevated with smoking and age

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4. Progestin-Only / Mini-Pill

• No estrogen component → suitable where estrogen is contraindicated
• Creates a relative estrogen-deficiency state → may cause irregular or continuous bleeding
• Higher failure rate (~1.2 per 100 woman-years) compared to COC

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5. Injectable Contraception

Combined Monthly Injection

• Contains short-acting natural estrogen + long-acting progestogen
• Administered once a month (every 4 weeks)
• Started within first 7 days of the cycle (or any day if pregnancy excluded, with backup contraception)
• Effectiveness: 0.05 pregnancies per 100 woman-years with frequent use

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6. Subdermal Implants

• Primarily levonorgestrel (progestin) implanted under the skin
• Prevents pregnancy for up to 5 years
• Often produces amenorrhea; otherwise well tolerated
• Pearl Index: very low (~0.05 per 100 woman-years)

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7. Intrauterine Device (IUD)

Description

• Flexible device (plastic) containing copper or a hormone, inserted into the uterine cavity
• Most popular contraceptive globally — ~140 million women use it

Types

Mechanism of Action

1. Impairs fertilization — reduces sperm motility
2. Copper exerts a spermatocidal effect
3. Prevents egg maturation
4. Induces aseptic (sterile) endometrial inflammation → disrupts implantation
5. Hormonal IUDs additionally thicken cervical mucus

Effectiveness

• 0.2–0.7 pregnancies per 100 women/year (Pearl Index)

When to Insert

⚠️ Copper IUDs are the most effective emergency contraception (99% efficacy)

Advantages

• High effectiveness, immediate for copper IUD
• Reversible and economical
• Safe for breastfeeding mothers
• Method of choice when COCs are contraindicated
• No need for additional contraception

Additional Benefits of Hormonal IUD (Mirena)

• Reduces menstrual pain and bleeding
• Treats: adenomyosis, idiopathic menorrhagia, uterine fibroids, endometrial hyperplasia
• Used in hormone replacement therapy

Contraindications (all IUDs)

• Pregnancy
• Postpartum/post-abortion sepsis
• Uterine developmental anomalies
• Pelvic inflammatory disease (PID)
• Unexplained uterine bleeding
• Trophoblastic disease
• Pelvic tuberculosis
• Cervical, vaginal, or ovarian cancer

Additional Contraindications (Hormonal IUD only)

• Insertion within 48 hours postpartum
• Migraine with neurological symptoms
• Breast cancer (current or history)
• Deep vein thrombosis / pulmonary embolism

Follow-Up

• Re-examine 4–6 weeks after insertion (post-first menstrual cycle)
• Bimanual examination required
• Ultrasound preferred to confirm position

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8. Male & Female Sterilization

Female Sterilization (Tubal Ligation)

• Permanent surgical contraception — blocks fallopian tubes
• Mechanism: prevents sperm reaching the egg
• Immediate effect
• Effectiveness: ~5 pregnancies per 1,000 women in Year 1; ~18 per 1,000 over 10 years

Male Sterilization (Vasectomy)

• Blocks vas deferens
• Not immediately effective — ducts take ~3 months to clear of sperm
• Additional contraception required for 3 months post-procedure
• After 3 months: 99.8% effective (2 pregnancies per 1,000 female partners)
• Failure rate: 0.02 per 100 woman-years — the most effective method overall

Advantages (both)

• High effectiveness
• Safe — complications limited to infection/anaesthesia risks
• Does not affect libido, sexual spontaneity, or hormonal cycle

Disadvantages

• Surgical procedure with surgical risks
• Reversal is very difficult, expensive, and not guaranteed
• Does not protect against STIs
• Vasectomy requires backup contraception for 3 months

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9. Barrier Methods

Male Condom

• Thin sheath (rubber, vinyl, or natural material)
• Creates a mechanical barrier — prevents sperm entry
• Only method that protects against STIs (Grade A evidence)
• Effectiveness: 88–95%

Diaphragm & Cervical Cap

• Physical barriers placed over the cervix before intercourse
• Often used with spermicide for increased efficacy

Spermicides

• Chemical agents that inactivate or destroy sperm in the vagina
• Active ingredient: Nonoxynol-9
• Available as: creams, gels, ointments, aerosols, pills/suppositories
• Effectiveness: 71–89% (lowest among chemical methods)
• Duration of action: maximum 2 hours per application
• Contraindications: allergy to spermicide; high pregnancy risk (low efficacy alone)

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10. Natural Methods

Lactational Amenorrhoea Method (LAM)

• Breastfeeding suppresses GnRH → suppresses ovulation
• Effective only when: fully breastfeeding + amenorrhoeic + baby <6 months old

Other Natural Methods

• Rhythm/Calendar method — avoid intercourse around predicted ovulation (~15.5 failures/100 woman-years)
• Withdrawal (coitus interruptus) — ~6.7 failures/100 woman-years

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11. Emergency Contraception

Methods Available

1. Progestin-only pills (levonorgestrel) — taken within 72 hours
2. COC (Yuzpe regimen) — combined pills in two doses
3. Mifepristone — progesterone antagonist; also used for medical abortion
4. Copper IUD — inserted within 5 days of unprotected sex

Mechanism

• Exact mechanism not fully established
• Primary action: inhibits or delays ovulation
• Does not terminate an established pregnancy

Effectiveness (within 72 hours of unprotected sex)

💡 The copper IUD is the most effective emergency contraception and can then serve as long-term contraception.

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Quick Comparison Summary

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