2

Contraception

10/12/2024
3 Contraception

Hormonal Contraception Non Hormonal Contraception

o OCP o IUD- Copper
o Transdermal –
Patch- Evra
o Essure
o Vaginal ring- o Tubal ligation
Nuva Ring
o IM progestin-
o Condoms
Depo Provera o Diaphragm
o Emergency
contraception
o IUD-Mirena
10/12/2024
4
The Pearl Index

o Created by Raymond Pearl 1933

o Definition- the number of failures per 100 women-years of exposure.
o In the denominator- total months or cycles of exposure from onset of
method until completion of the study/treatment .
o The PI is usually based on a lengthy exposure (1 yr), and therefore fails
to accurately compare methods at various durations of exposure.

10/12/2024
 Hormonal CCs
Synthetic female sex
steroids

E+P P only
 Hormonal CCs
Administration

Oral

Patch Implant

Injection Vaginal ring

7
History

o The first hormonal contraceptive- Enovid , PO (150 ug

of mestranol and 9.85 mg of norethynodrel) was
approved by the FDA in 1960 (Pincus G. and Rock J.)

o OCP – most widely used reversible form of hormonal contraceptive

10/12/2024
 Hormonal CCs
Steroid Hormones
o Rapidly absorbed in the gut

o Portal circulation  liver metabolism 

inactivation

o High doses of steroids are required when orally

administered
 Hormonal CCs
Progestin (c-21)

Differ from each other in their

o Affinity for ER, AR and PR
o Ability to inhibit ovulation
o Ability to substitute for progesterone and antagonize
 Hormonal CCs
Estrogen
o Ethinyl estradiol – the main E in use

o High dose OCP- 30 to 35 ug of EE (50ug)

o Low dose OCP - 15-20 ug EE

o Effective contraceptive agents in women at reproductive

age (0.07-2.1 preg per 100 woman yrs of treatment)
 Hormonal CCs
Contraceptive effect- Combined OC
o E or P alone can inhibit ovulation
o They inhibit GT synthesis by acting on the pituitary
gland.
o Progestin mainly inhibits LH secretion (prevent ovulation)
o Estrogen- suppresses FSH secretion( the development of
a leading follicle)
o In combination – inhibition of ovulation at lower doses,
(the effect is dose related!)
o The progestin also acts on the endometrium, cervical
mucus and on the fallopian tubes
12
Hormonal CCs
 First generation OCP- products containing more
than 50 ug EE
 Second generation OCP- products containing EE
20-35 ug and levonorgestrel or norgestimate.
 Third generation OCP- EE 20-35 ug with
desogestrel or gestodene
 Fourth generation- products containing
drospirenone, dienogest or nomegestrol acetate.

 Extended /continuous regimen OCP

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13
Hormonal CCs
Extended OC therapy:
o In 2003 the FDA approved Seasonale, a 91- day
OCP(84 days of 30ug EE +0.15 mg levonogestrel
+7 days of inactive pills).
o Seasonique-(2006) the same dose of EE +
levonogestrel during the first 84 days but with 0.01
mg estrogen instead of the placebo pills
o In 2007- Lybrel- 1 yr continuous extended active
pills (20 ug EE with 0.09 mg of levonorgestrel)

10/12/2024
14
Hormonal CCs

o Resulted in fewer bleeding days, decrease pain associated with

menstruation
o Safety and S/E profiles similar to the 21 days cyclic pills
o 99% of women resume ovulation within 3 months of discontinuing the
medication
Side effects- OCP

o Nausea, breast tenderness, weight gain, headaches

o Less common with current LD OCs

o Usually resolve after the first few cycles

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 Hormonal CCs
Teratogenicity
No increase in overall risk for
 Malformation

 Congenital heart defects

 Limb reduction defects

 HD-E taken in pregnancy can induce vaginal Ca in

exposed female offspring in utero

 Hormonal CCs

Transdermal - Evra
 Patch- a combination of 20mg of EE and 150mg of noregestromin

daily, one patch weekly for 3 weeks

 Peak steroid levels < OCs but sufficient to prevent ovulation

 Greater convenience  improves compliance

 the mean serum EE levels are higher compare with the

combined OCP (30ug of EE)

 Hormonal CCs
NuvaRing
o A combined estrogen/progesterone contraceptive
vaginal ring with low mean serum EE levels.
o Release of 15 mg of EE and 120 mg of etonogestrel daily
o outer diameter - 54mm
o Cross section - 4mm
o Use for 3 weeks+ 1 week free
o S/E- headaches, leukorrhea and vaginitis
o Failure rate- 0.65 per 100 woman years
o Fewer days of irregular bleeding/spotting than women
taking OCs
Hormonal CCs
NuvaRing
S/E- headaches, leukorrhea and vaginitis 

Failure rate- 0.65 per 100 woman years 

Fewer days of irregular bleeding/spotting than women 

taking OCs

Can be removed during 

coitus. Reinsertion within

3 hours
 Hormonal CCs
Depo Provera
(medroxyprogesterone acetate)
o A single 150mg IM dose  ovulation suppression for 14 wks
o 2004- FDA approved depo-subQ-provera, 104 mg for s/c use
o Injected every 3 months
o Highly effective
o Breakthrough bleeding in new users
o Return to fertility may be delayed
o Median time to ovulation after last injection – 10 months.
o 70% conceive within 1 yr
o 90% conceive within 2 yrs
‫‪20‬‬ ‫‪Hormonal CCs‬‬

‫סיאנה של חברת פייזר (‪ ,)Sayana‬זריקה חדשה למניעת הריון אשר מכילה פרוגסטרון‬
‫בלבד במינון נמוך וניתנת רק ‪ 4‬פעמים בשנה‪ .‬סיאנה פועלת ב‪ 3-‬מנגנונים על מנת למנוע‬
‫הריון ‪ :‬דיכוי ביוץ‪ ,‬עיבוי רירית צוואר הרחם ובכך עוצרת מעבר של תאי זרע‪ ,‬והפיכת רירית‬
‫הרחם לדקה ובכך מונעת השתרשות בייצית מופרית ברחם‬

‫‪10/12/2024‬‬
 Hormonal CCs
Depo Provera
Safety (long use)

o DMPA  E production↓  bone loss

o Adolescents are of especial concern

o FDA “black box warning”

DMPA treatment be limited to 2 years at a time unless

the patient has no other good options for contraception

Hormonal CCs
Emergency CC
 Hormonal CCs
Emergency CC
1. High dose E
 Taken within 72 hours of coitus
5 mg of EE daily for 5 days
 Possible mechanisms
 Altered tubal motility
 Interference with CL function
 Alteration of the endometrium
 Pregnancy rate - 0.15%
 Hormonal CCs
Emergency CC
2. E+P - Yuzpe
 EE 100 ug and levonorgestrel 0.5 mg in 2 doses 12 hr
apart ,up to 72 hr after intercourse. (Preven)
 Effective in inhibition or delay of ovulation
 Pregnancy rate - 1.8%, but it is 1.2% if treatment is
started within 12 hours of intercourse
 Nausea and vomiting are common with both regimens
 Hormonal CCs
o Emergency CC
3. Plan B , Ella - Levonorgestrel Alone
o 0.75 mg initially followed by another 0.75 mg 12 hours
later- up to 72 hr after intercourse
o 1.5 mg levonorgestrel in one dose up to 72 after
intercourse.
o The emergency CC method
of choice at present
o Less nausea and vomiting
 Hormonal CCs
Emergency CC
4. Copper IUD
o Most effective emergency contraceptive
method
o Insertion of a copper IUD within 7 days
 Hormonal CCs Benefit
Neoplasia- Endometrial Cancer
o OCP use is associated with lower risk of endometrial CA

o 2yrs  ↓ risk by 40%

o > 4yrs  ↓ risk by 60%

o Benefit continues for at least 15 years from last use !!!

Neoplasia- Ovarian Cancer

o OCP decrease the risk for ovarian CA

o Most probably via the protective effect of the

o progesterone

o 3-4yrs  ↓ risk by 50%

o > 10yrs  ↓ risk by 80%

o Benefit continues for at least 15 years from last use !!!

28
Hormonal CCs Benefit
Neoplasia- Colon Cancer

o Growing evidence of protective effect

o 37% reduction in colon cancer

o 34% reduction in rectal cancer

10/12/2024
 Hormonal CCs
Neoplasia- Cervical Cancer

 There may be a weak association ???

 Risk factors for Cx Ca ….

 OCs use   ↓ Barrier methods

Sexual
Exposure to HPV
intercourse
Hormonal CCs
Neoplasia- Breast Cancer

 Generally, very small increase risk in current OC users

under 35 yo, RR-1.24(Practice Committee of American
Society for Reproductive Medicine 2008)

Current use Discontinuation

RR 1.24 1-4 yrs  RR 1.16

5-9 yrs  RR 1.07
> 10 yrs  RR 1.0
Hormonal CCs
Neoplasia Breast Cancer
o Breast CA diagnosed in OCP user was less advanced

o No increased risk in the 35-64 yo who were past users

(Kahlenborn et al 2006, Floger et al 2007)

For the present, the best

information available is
reassuring that there is
little or no direct
association
Hormonal CCs
Neoplasia Liver Tumors
o Association to liver adenomas
o Risk is related to prolonged use
o Usually regress when OC use is discontinued
o Newer low-dose OCs pose less risk
o M/P no association to liver cancer
33

10/12/2024
 IUD
Copper IUD Hormonal IUD
approved for up to Levonorgestrel-
10 (7) years of releasing IUD
continuous use (Mirena) approved
for 5 years of use
(52 mg)
IUD
36

10/12/2024
 Sterilization - Female
Methods
o Tubal sterilization at the time of
laparotomy for a CS or other abdominal
operation
o Laparoscopy
o Hysteroscopy
 Sterilization - Female
Hysteroscopy

In 2002, the FDA approved a new

hysteroscopic method of permanent birth
control:
the Essure system
Non-hormonal Methods

Fertility Awareness
Eficacy
Sperm may survive 5 to 7 days in the female genital 
tract

Even a week's abstinence around the time of actual 

!!! ovulation offers no guarantee against pregnancy

!!! PI – perfect use 2-9%, typical use up to 25% 

Non-hormonal Methods

Coitus Interruptus
o Withdrawal of penis before ejaculation

o A very important means of fertility

control in many countries
o Pregnancy has occurred from
ejaculation on the female
external genitalia !!
Non-hormonal Methods

Breastfeeding Lactation Amenorrhea

 PRL ↑  GnRH ↓  GT ↓  Ovulation is suppressed
 Duration of suppression is variable:

 Frequency of nursing

 Length of time since birth

 The mother's nutritional status

Non-hormonal Methods

Breastfeeding
 Time - ovulation eventually returns but is unlikely

before 6 months, especially if

 The woman is fully breastfeeding

 No supplemental foods given to the infant

Non-hormonal Methods

Breastfeeding
Frequency 

Intervals ≤ 4h during the day and 6h at night 

Supplemental feeding ≤ 5-10% of the total amount of feeding 

Non-hormonal Methods

Fertility Awareness
Mucous Method
The woman attempts to feel the cervical mucus with her 
fingers

E influence  quantity and elasticity ↑ progressively until [peak] 

P influence  scant and dry 

until onset of the next menses
Non-hormonal Methods

Fertility Awareness
Symptothermal Method
The 1st day of abstinence is predicted either from the 

Calendar, by subtracting 21 from 

…cycle length or

1st day mucus is detected 

Non-hormonal Methods

Fertility Awareness
Symptothermal Method
The end of the fertile period is predicted by use of basal 
body temperature

Temp’ - every morning 

Intercourse may be resumed 

3 days after the thermal shift
(the rise in body t’ that signals that the
CL is producing P)
Non-hormonal Methods

Vaginal Spermicides
Nonoxynol-9

Less effective than condoms / diaphragms 

Higher rates of genital lesions  may ↑ the risk for STDs 

and HIV

Toxic to the lactobacilli. 

Regular use  ↑ vaginal
colonization with the E. coli
may predispose to bacteriuria after
intercourse
Non-hormonal Methods

Barrier Methods
Condom - male
In the 1700s, condoms made of animal intestine were 

used by the aristocracy of Europe

Condoms were not widely 

available until the discovery

of rubber in the 1840

Non-hormonal Methods

Barrier Methods
Condom - male
Condoms lubricated with the spermicide nonoxynol-9 
are more effective

Risk breakage is about 3% 

Related to friction 

Use of lubricants may reduce 

the risk
Non-hormonal Methods

Barrier Methods
Condom - male
Barrier methods reduce the risk of STDs

Chlamydia, HSV-2, HIV and HBV do not penetrate latex 

!! condoms

Nonoxynol-9 should not be 

used with condoms for HIV
protection because it has been
associated with genital lesions
Non-hormonal Methods

Barrier Methods
Condom - male
reduction in cervical neoplasia 60-80% 

Presumed mechanism  reduced transmission of human 

HPV
Non-hormonal Methods

Barrier Methods
Diaphragm
A circular spring covered with fine latex rubber 
Non-hormonal Methods

Barrier Methods
Diaphragm
The practitioner must 

Fit the diaphragm for the patient 

Instruct her in its insertion and 

Verify by examination that she can insert it correctly to cover the 

cervix and upper vagina

Spermicide is always prescribed 

Non-hormonal Methods

Barrier Methods
Diaphragm
The diaphragm should open
easily in the vagina and fill the
fornices without pressure
The largest diaphragm that fits
comfortably should be selected
A size 65, 70, or 75mm
diaphragm will fit most women
Non-hormonal Methods

Barrier Methods
Diaphragm
Insertion - several hours before 
intercourse
If intercourse is repeated, additional 
spermicidal jelly should be inserted
into the vagina without removing the
diaphragm
Removal - at least 6 hours after
intercourse
Non-hormonal Methods

Barrier Methods
Diaphragm
Prolonged use  ↑ risk of bladder infections 
Risk increases with no. of days the diaphragm is used in 
a week