Contraception For The 21st Century

CONTRACEPTION FOR ST THE 21 CENTURY

Development in contraception Not at pace of tech dev:  Dev however note worthy and attitude in developing countries changing  Slow pace Extensive research and rigorous clinical trials Govt approval Cost benefit to company and concumers 

New contraceptives Modifications of old one : No need to change winning team Cost Medicolegal issues Clinical trials shorter 

New innovations for the 21st century  

 



Not all covered Focuses on innovations that are more effective, easier to deliver Fewer side effects than available methods New info on existing ones

Methods    

Physical Behavioral Medical Surgical

VAGINAL RINGS Two types : combined and po  Combined estrogens and progestin rings Good cycle control, steady delivery of hormones > OC Under a woman's control: insertion and removal; any where in vagina that is most comfortable/ upper vagina 

RINGS   

Continuous use: all day/ all night Difuses into vagina- into blood Can be removed up to 3 hrs for comfort for cleaning and sex

TWO COMBINED VAGINA RINGS NuvaRing ( organon)  Available in brazil, chile Release 120ug of etonogestrel and 15ug of EE/ day Use for 3 wks. Rest for 1 wkwithdrawal bleeding U may skip this’ Use new one per month 

RING: CLINICAL TRIAL Realeases 150ug of nestorolone and 15ug of EE/day For developing countries: use for 1 year Use for 3 rest for 1 and reuse effectiveness 1.2 preg per 100 women in 1st year of use 

Side effects  

Abnormal bleeding < COC s/e of COC but less

TWO PROGESTIN- ONLY RINGS 







PROGERING: PROGESTERONE UNNAMED RING: Synthetic progestin ; nestorone Effects on cervix , endometrium, ovulation Less effective than combined , best in B/F( decrease fert).

Progesterone rings Best in lactating women  Releases 10mg of progesterone/day Lasts for 1 year  S/E Infection, bleeding problems 

Nestorone rings   



Contains nestorone{ ST1435), Releases 50-100ug /day Best in lactation, no passage in breast milk Not in market

Rings 



Acceptability : easy, to insert, use and remove Non acceptability: too much responsibility on woman

Transdermal contraception  

Patch; combined prep Sprays, gels: progestin

Combined patches Ortho Evra( ortho—McNeil) Releases 150ug of norelgestromin and 20ug of EE. Patch change wkly for 3wks, 1wk free 

Design 



 

Square patch-4.45cm , diff. colors 3 layers; outer protective polyester layer, middle medicated adhesive layer and a clear polyester- removable Delivers hormones thru skin Placed on any part of body

Design    

Adheres to skin: normal activity even bathing Reduce adhesion: creams, oils powder, makeup. As effective as COC. Better compliance Experimental patch: 3.16 cm release 50ug gestodene and 18ug of EE/day.

Correct use  



 

Within 5 days of menses Change every wk with a new one for 3 wks in a new location 4th wk: no ; for withdrawal bleeding Studies on for continous use Good compliance

Effectiveness 0.6 of every 100 women get preg  < with wt > 90kg same for COC. INCREASE METABOLISM/ FAT STORAGE 

S/E: skin irritation/rash. Effects of COC but much less.

SPRAY ON CONTRACEPTIVES 



RESEACH: PROGESTIN ( nestorolone); spray and gel Given daily: dries fast and immediately absorbed: suppresses ovulation

CONTRACEPTIVE IMPLANTS Decrease nos of rods and capsules  Change of progestins  Minimise S/E esp bleeding  Safety in B/F NORPLANT : 6 CAPS S/E bleeding 

Newer implants   



1 to 2 rods or caps Rods> casules Rods: filled with steroid crystals and polymer Capsules: hollow polymer tubes filled with free steroid crystals

New implants 

 

Jadelle and implanon. Nestorolone is not in market Expensive to develop Require training to insert

new implant system 

 



Few caps or rods: insertion/ removal easier Few compl./ less discomfort Newer implants : specially designed applicator, no need for separate incision Insertion less than 5 mins

New formulation with fewer rods Jadelle and chinese nos 2 : levonorgestrel  Implanon: etonogestrel  Elcometrine and nestorolone: ST1235 Cervix, endometrium, ovulation 

Levonogestrel implants Jadelle and chinese nos 2 : 2 rods Delivers same dose of levonorgesterel but at higher rate 140mg Easier to insert and remove Chinese nos 2 : sinoplant : 150mg levonorgestrel 

Etonogestrel implants  

Implanon: single rod; 3 yrs Complete suppression of ovulation> norplant

Nestorone implants  



  

ST 1435: under dev. Effect for 2 yrs Single rod made of silicone membrane Useful in B/f women. None in breast milk Less irregular bleeding S/E Bleeding disorder as for all progestins: low preg

COMBINED INJECTABLES 

  

PROGESTINS AND ESTROGENS MONTHLY INJ. Better cycle control and Early return of fertility

Examples 

 

Cyclofem, cycloprovera, mesigyna Dev on for some time Not widely available

Effectiveness Inhibits ovulation, acts on cervix and endometrium  0.1 to 0.4 preg for every 100 women  Quick return of fertility: 6 wks  S/E Side effects of COC. Lack of access Better in S/E esp bleeding PROGESTINS 

INNOVATION  



NEW DMPA FORMULATION DMPA-SC- subcut inj ( uniject) : self administered: newly approved Slower and sustained absorbtion: contains 104 mg of DMPA

NEW 



CYCLOFEM/ CYCLOPROVERA. FEMINENA/LUNELLE/LUNELL A: 25mg MPA + 5mg estradiol cypionate MESIGYNA/NORIGYNON: 50mg norethisterone enanthate+ 5mg estradiol valerate

CONDOMS 



MALE / FEMALE: non latex and latex Protects against HIV

MALE CONDOMS Synthetic nonlatex: polyurethrane, styrene ethylene butylene styrene (SEBS) sold as tactylon 

Non latex condoms Poyurethrane and SEBS Longer shelf life Can be used with oil based lubricants Less odor, more comfortable, less constricting Transfer heat and sensation better 

Use Poly urethrane: in use since 1995  SEBS : not marketed  Widely popular despite More breakage, slippage 

FEMALE CONDOMS 



ONLY available is FC Female condom( formerly Reality): polyurethrane: costly Newer ones- the FC2, the VA feminine, PATH womens condom condom- latex rubber : less cost

Fertility awareness method Two new variations The standard days method Two day method Uses Couple do want clinical methods, or lack of access 

Conditions   

Involvement of both partners Communicate about sex Women empowerment

The standard days method  



Identification of fertile and infertile phase of cycle Use of color coded beads : cycleBeads repesenting cycle. Moves a rubber ring to the next bead every day. When on white: fertile phase Fertile window: several days B4 and few hrs after ovulation

Timing 

   

Computer simulation: variation in individual cycle and in various women Fertile period: days 8 and 19 0f cycle #CYCLE HAVE TO BE BE 26 TO 32 DAYS. Effectiveness Like barrier: 5 to 12 preg/hwy

Two day method 



Any cycle length irrespective of regularity Avoid intercourse for 10—15 days per cycle

Method Fertile : cervical mucus yesterday and today  Infertile : no cervical mucus for two consecutive days  Better and less cumbersome than Billings and symptothermal 

Effectiveness 

Like barrier

ORAL CONTRACEPTIVES Basis of new one Decrease S/E and increase effectiveness NEW ONES Continous use COC COC with new prgestin New POP 

CONTINOUS- USE ORAL CONTRACEPTIVES WHY NOT. ? USE OF PILL BREAK  Break : mimic natural cycle  CONTINOUS USE: Reduce nos of bleeding days/ year Reduce S/E of hormone break: haedache, migraines, premenstrualsyndrome,mood swings 

PROBLEMS 



Breakthrough bleed. Decrease with long use Seasonale : in use now.cont. use; contains 150ug levonorgestrel and 30u of EE: use for 84 days( 12 wks) with 7 day break

Drospirenone COC Yasmin : 3mg drospirelone and 30ug EE  Advantages Reduce acne and excess hair growth Less water retention and wt gain S/E same as for COC 

Desogestrel POP    

CERAZETTE: 75ug desogestrel Primarily inhibits ovulation Can be 12 hrs late for taking it 0.2 preg/ hwy

INTRAUTERINE DEVICES NEW Insertion and removal easier Reduce expulsion , pain and bleeding Examples IUS- PROG containing Frameless IUD (GyneFix) 

Progestin releasing IUS MIRENA: levonorgestrel; 20ug/day: use for 5 yrs  As effective as sterilisation  Preg: 0.1 –0.2 per 100 women in 1 year. In 5yrs : 0.5—1.1  S/E Minimal and similar to others but better than other iud 

Frameless IUD   

 

GyneFix NO PLASTIC T SHAPE FRAME Several copper cylinders tied together on a string Anchored 1cm deep into fundus Cause less pain and bleeding

GyneFix DECREASE BLEEDING  INCR. EXPULSION  DIFF INSERTION TECHNIQUE  HIGH SKILL OTHERS FibroPlant-LNG FRAMELESS Contains LNG 

TRANSCERVICAL FEMALE STERILIZATION     



Safer and easier Chemicals : quinacrine Plugs: Adriana method Microcols: essure Old methods: minilap, lap.; skilled persons, sterile condition Newer methods : increase access: no surgery

ESSURE-MICROCOIL 

  



Spring like device inserted via hysteroscope via cervix into tubes Scar tissue form over it in 3 months Local anaesthesia< 1 hour 90% success 3months: x-ray or USS to check placement of microcoil

Effectiveness   



Like BTL Not reversible Back up contraception till 3 months Expensive

Quinacrine- a chemical compound Pellets inserted into uterustubal scarring  No physician needed  Safety test ongoing  Less effective than BTL 1 to 2 preg/hwy. more in 5 years 

Adiana procedure 

 

Via hysteroscope insert catheter: deliver low level radiofrequency- superficial lesion then insert a plastic implant called matrix into lesion In 3 months scar tissue Expensive also for dev. countries

Male hormonal contraception  





Ongoing clinical trials Uses testosterone with or without progestins to suppress spermatogenesis Formulations : pills patches,inj, implants Others : reversible vas occlusion

Testosterone – only formulations  





International reseach Wkly inj. Of 200mg testosterone enanthate Chinese study advanced: testosterone undecanoate inj. Is monthly Combined therapy better in nonasians

Combined formulations Progestins> GnRh analogue: speeds and improves suppression of sperm production- less testosterone  S/E NO EFFECT ON MALE SEX DRIVE OR AGGRESSION Wt gain, dec.HDL 

EFFECTIVENESS 



< 1 million sperms per ml of ejaculate- 1.4 preg per year among partners of 100 men Acceptability is high

New long term male contraception in clinical trials  



RISUG and the Intra Vas device RISUG: Injected Gel blocks sperm Revesible inhibition of sperm under Guidance: is a clear gel made of styrene maleic anhydride(SMA) mixed with dimethyl sulfoxide (DMSO)

TECHNIQUE 



Inj. Into vas deferens: blocks flow Reversible: flushed out with DMSO or NaHco3 or via massage, vibration or low level electrical current

Intravas device: Two implanted plugs block sperm  

Nonsurgical reversible

Gene based approaches 

 

Contraceptives target genes controlling sperm and egg production or the proteins controlling fusion of egg and sperm Decade away from realisation S/e minimal