Emergency Contraception
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SUMOLLY ANAK DAVID 21ST JANUARY 2009
Emergency contraception (also known as postcoital contraception and the morning-after pill) typically refers to the administration of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or to those who have had a failure of another method of contraception ( missed OCP, expulsion of IUD, burst, split, dislodge condoms) ref: Baiden et al. 2002
The length of menstrual cycle is 28 days
Each cycle consists of the : i) Menstrual phase (days 1-5) ii) Follicular phase (days 1-13) iii) Ovulatory phase (days 10-18) iv) Luteal phase (days 15-28)
The mechanism of action is uncertain and may vary depending upon the day of the cycle the drug is administered. Emergency contraceptives may act by inhibiting or delaying ovulation, interfering with fertilization or tubal transport, preventing implantation by altering endometrial receptivity, or possibly causing regression of the corpus luteum. Since these drugs are administered within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of emergency contraception does not interrupt pregnancy or harm a developing embryo EC is effective only in the first few days following intercourse before the ovum is released from the ovary and before the sperm fertilizes the ovum.
HORMONE ◦ Progestin only EC ◦ Combined progestin-estrogen EC
INTRA-UTERINE CONTRACEPTIVE DEVICE
inhibit the pre-ovulatory luteinizing hormone (LH) surge, impeding follicular development and maturation and/or the release of the egg may interfere with sperm motility by thickening the cervical mucus, which prevents sperm from reaching the egg, thus inhibiting fertilization Recommended dose is 0.75mg taken within 72 hour and the second dose 12H later, though a single dose of 1.5mg have been used
1.
2. 3.
4.
Suppress the midcycle peak of luteinizing and folicle-stimulating hormone - only able to suppress ovulation in half of the cycle Produce hostile cervical mucus - prevent sperm penetration Reduce cilia motion in the fallopian tube and decrease motility of the uterus and oviduct, thus inhibiting ova and sperm transport. Reducing the size and number of endometrial glands, thus inhibiting implantation Ref: (Donna & Siri 2006
Quantity and quality of breast milk do not seem harmed (In contrast, combined oral contraceptives can slightly reduce milk production.) No estrogen side effects. Do not increase risk of estrogen-related complications such as heart attack or stroke. effective during breastfeeding (start 6 weeks after childbirth). Even less risk of progestin-related side effects, such as acne and weight gain, than with combined oral contraceptives. May help prevent: – Benign breast disease, – Endometrial and ovarian cancer, – Pelvic inflammatory disease. ref: Robert 1997
Involved the use of levonorgesterol Effective if dose is taken within 72 hours (3 days) of unprotected sexual intercourse. 1.5mg as a single dose within 72 H If vomiting occurs within 3 hours, a replacement dose can be given
Common side effects: Irregular menstrual periods Headache Breast pain Upset stomach Dizziness Acne Increased hair growth (medline)
Serious side effects: Bleeding that lasts a long time Lack of menstrual periods Severe stomach pain
Yuzpe regimen consists of combined oral contraceptives—estrogen and progestin, taken within 72 hours (three days) of unprotected intercourse, followed by a second dose 12 hours later Nausea and vomiting are the major side effects of the regimen
A) The estrogen inhibits FSH release, therefore follicle development. B) The progesterone inhibits LH release, therefore ovulation, and makes cervical mucus inhospitable for sperm. Together, they make the endometrium unsuitable for implantation. (Rang et al 2003)
Depression Mood disturbance Nausea & vomiting Headache Breast tenderness Change in body weight Fluid retention
Advantage Reduced dysmenorhea, menorrhagia Reduced risk of pelvic inflammatory disease (c/t IUD)
doubling or tripling of the incidence of ◦ stroke, ◦ myocardial infarction, ◦ venous thromboembolism (VTE) Use of COC confers some risk of VTE, about 3-6 times that of non-users. While data are limited, evidence suggests that there is no increased risk of VTE among women who use progesterone -only methods or combined injectable contraceptives (Saadatnia & Tajmirriahi 2007).
◦ breast cancer in women under the age of 35
A copper intrauterine device placed within 120 hours of unprotected intercourse can also be used as a form of emergency contraception provides continuing contraception after the initial event. T-shaped polyethylene frame with 380 mm2 of exposed surface consisting of fine copper wire effect of copper may be related to in utero oxidation with release of copper ions. Copper ions may inhibit transtubal sperm migration, thus preventing zygote formation
A intrauterine device is a Tshaped piece of plastic placed inside the uterus. The piece of plastic contains copper or a synthetic progesterone hormone that prevents pregnancy. e.g. Copper-T 380A (ParaGard), Progestrone T (Progestasert), Levonorgestrel (Mirena)
The progesterone intrauterine device releases a constant low dose of a synthetic hormone continually throughout the day. Both the progesterone IUD and copper IUD prevent pregnancy in one of two ways: - The released progesterone or copper creates changes in the cervical mucus and inside the uterus that kills sperm or makes them immobile. - Changes the lining of the uterus, preventing implantation should fertilization occur
Mood changes Acne Headaches Breast tenderness Pelvic pain Cramping Increased bleeding during menstruation Nausea
have or ever had cancer in the uterus or cervix have unexplained vaginal bleeding may be pregnant have pelvic inflammatory disease have a history of ectopic pregnancy have Gonorrhea or Chlamydia are not in a mutually monogamous relationship
METHOD
SIDE EFFECT
CONTRAINDICAT EFFICACY ION
PROGESTERONE ONLY
Nausea 20%, vomiting 5% Headache, abd pain Breast tenderness
COMBINED PROESTERONESTROGEN
Nausea 50% Vomiting 20% Breast tenderness Weight changes spotting
35 yo Smoke , migraine High BP Thrombosis Heart attack, stroke Breastfeeding
75%
IUD
Heavy menses dysmenorrhea Pelvic infection
Pregnant Std Previous ectopic
99%
89%.
Progestin only ◦ 2 pills within 120h
Estinor®, Postinor ®, postinor-2 50 pills within 120h microlut 35 Progestin + estrogen (the first 21 pill only) ◦ 2 pills within 120h and another 2 12H later eugynon ®, neogynon ®, nordiol
◦ 4 pills within 120H & 12H later
microgynon®, riget®, nordette®, rigevidon®
◦ 5 pills within 120h and 12h Later loette®
ref: IPPF.com
hhtp//www.uptodate.com British National Formulary (BNF). 2005. BMJ Publishing Group Ltd, London. Donna S. & Siri, L.K. 2006. Progestin-only oral contraceptive. The handbook of contraception: A guide for practical management. Humana Press. Wells, B.G. 2006. Gynecologic and Obstetric disorders (Contraception). In: Wells, B.G., DiPiro, J.T., Schwinghammer, T.L. & Hamilton, C.W. Pharmacotherapy handbook. Boston: McGrawHill MIMS. 2005. CMPMedica Pacific Ltd, Hong Kong Pharmacotherapy Handbook 6th Edition. Elizabeth Wesley. Emergency Contraception: A Global Overview. Supplement 2 1998
Robert, A.H. 1997. Progestin-only oral contraceptive. The essentials of contraceptive technology. Saadatnia, M. & Tajmirriahi, M. 2007. Hormonal Contraceptives as a risk factor for cerebral venous and sinus thrombosis. Acta Neurologica Scandinavica 115(5) : 295-300.
Emergency contraception (also known as postcoital contraception and the morning-after pill) typically refers to the administration of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or to those who have had a failure of another method of contraception ( missed OCP, expulsion of IUD, burst, split, dislodge condoms) ref: Baiden et al. 2002
The length of menstrual cycle is 28 days
Each cycle consists of the : i) Menstrual phase (days 1-5) ii) Follicular phase (days 1-13) iii) Ovulatory phase (days 10-18) iv) Luteal phase (days 15-28)
The mechanism of action is uncertain and may vary depending upon the day of the cycle the drug is administered. Emergency contraceptives may act by inhibiting or delaying ovulation, interfering with fertilization or tubal transport, preventing implantation by altering endometrial receptivity, or possibly causing regression of the corpus luteum. Since these drugs are administered within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of emergency contraception does not interrupt pregnancy or harm a developing embryo EC is effective only in the first few days following intercourse before the ovum is released from the ovary and before the sperm fertilizes the ovum.
HORMONE ◦ Progestin only EC ◦ Combined progestin-estrogen EC
INTRA-UTERINE CONTRACEPTIVE DEVICE
inhibit the pre-ovulatory luteinizing hormone (LH) surge, impeding follicular development and maturation and/or the release of the egg may interfere with sperm motility by thickening the cervical mucus, which prevents sperm from reaching the egg, thus inhibiting fertilization Recommended dose is 0.75mg taken within 72 hour and the second dose 12H later, though a single dose of 1.5mg have been used
1.
2. 3.
4.
Suppress the midcycle peak of luteinizing and folicle-stimulating hormone - only able to suppress ovulation in half of the cycle Produce hostile cervical mucus - prevent sperm penetration Reduce cilia motion in the fallopian tube and decrease motility of the uterus and oviduct, thus inhibiting ova and sperm transport. Reducing the size and number of endometrial glands, thus inhibiting implantation Ref: (Donna & Siri 2006
Quantity and quality of breast milk do not seem harmed (In contrast, combined oral contraceptives can slightly reduce milk production.) No estrogen side effects. Do not increase risk of estrogen-related complications such as heart attack or stroke. effective during breastfeeding (start 6 weeks after childbirth). Even less risk of progestin-related side effects, such as acne and weight gain, than with combined oral contraceptives. May help prevent: – Benign breast disease, – Endometrial and ovarian cancer, – Pelvic inflammatory disease. ref: Robert 1997
Involved the use of levonorgesterol Effective if dose is taken within 72 hours (3 days) of unprotected sexual intercourse. 1.5mg as a single dose within 72 H If vomiting occurs within 3 hours, a replacement dose can be given
Common side effects: Irregular menstrual periods Headache Breast pain Upset stomach Dizziness Acne Increased hair growth (medline)
Serious side effects: Bleeding that lasts a long time Lack of menstrual periods Severe stomach pain
Yuzpe regimen consists of combined oral contraceptives—estrogen and progestin, taken within 72 hours (three days) of unprotected intercourse, followed by a second dose 12 hours later Nausea and vomiting are the major side effects of the regimen
A) The estrogen inhibits FSH release, therefore follicle development. B) The progesterone inhibits LH release, therefore ovulation, and makes cervical mucus inhospitable for sperm. Together, they make the endometrium unsuitable for implantation. (Rang et al 2003)
Depression Mood disturbance Nausea & vomiting Headache Breast tenderness Change in body weight Fluid retention
Advantage Reduced dysmenorhea, menorrhagia Reduced risk of pelvic inflammatory disease (c/t IUD)
doubling or tripling of the incidence of ◦ stroke, ◦ myocardial infarction, ◦ venous thromboembolism (VTE) Use of COC confers some risk of VTE, about 3-6 times that of non-users. While data are limited, evidence suggests that there is no increased risk of VTE among women who use progesterone -only methods or combined injectable contraceptives (Saadatnia & Tajmirriahi 2007).
◦ breast cancer in women under the age of 35
A copper intrauterine device placed within 120 hours of unprotected intercourse can also be used as a form of emergency contraception provides continuing contraception after the initial event. T-shaped polyethylene frame with 380 mm2 of exposed surface consisting of fine copper wire effect of copper may be related to in utero oxidation with release of copper ions. Copper ions may inhibit transtubal sperm migration, thus preventing zygote formation
A intrauterine device is a Tshaped piece of plastic placed inside the uterus. The piece of plastic contains copper or a synthetic progesterone hormone that prevents pregnancy. e.g. Copper-T 380A (ParaGard), Progestrone T (Progestasert), Levonorgestrel (Mirena)
The progesterone intrauterine device releases a constant low dose of a synthetic hormone continually throughout the day. Both the progesterone IUD and copper IUD prevent pregnancy in one of two ways: - The released progesterone or copper creates changes in the cervical mucus and inside the uterus that kills sperm or makes them immobile. - Changes the lining of the uterus, preventing implantation should fertilization occur
Mood changes Acne Headaches Breast tenderness Pelvic pain Cramping Increased bleeding during menstruation Nausea
have or ever had cancer in the uterus or cervix have unexplained vaginal bleeding may be pregnant have pelvic inflammatory disease have a history of ectopic pregnancy have Gonorrhea or Chlamydia are not in a mutually monogamous relationship
METHOD
SIDE EFFECT
CONTRAINDICAT EFFICACY ION
PROGESTERONE ONLY
Nausea 20%, vomiting 5% Headache, abd pain Breast tenderness
COMBINED PROESTERONESTROGEN
Nausea 50% Vomiting 20% Breast tenderness Weight changes spotting
35 yo Smoke , migraine High BP Thrombosis Heart attack, stroke Breastfeeding
75%
IUD
Heavy menses dysmenorrhea Pelvic infection
Pregnant Std Previous ectopic
99%
89%.
Progestin only ◦ 2 pills within 120h
Estinor®, Postinor ®, postinor-2 50 pills within 120h microlut 35 Progestin + estrogen (the first 21 pill only) ◦ 2 pills within 120h and another 2 12H later eugynon ®, neogynon ®, nordiol
◦ 4 pills within 120H & 12H later
microgynon®, riget®, nordette®, rigevidon®
◦ 5 pills within 120h and 12h Later loette®
ref: IPPF.com
hhtp//www.uptodate.com British National Formulary (BNF). 2005. BMJ Publishing Group Ltd, London. Donna S. & Siri, L.K. 2006. Progestin-only oral contraceptive. The handbook of contraception: A guide for practical management. Humana Press. Wells, B.G. 2006. Gynecologic and Obstetric disorders (Contraception). In: Wells, B.G., DiPiro, J.T., Schwinghammer, T.L. & Hamilton, C.W. Pharmacotherapy handbook. Boston: McGrawHill MIMS. 2005. CMPMedica Pacific Ltd, Hong Kong Pharmacotherapy Handbook 6th Edition. Elizabeth Wesley. Emergency Contraception: A Global Overview. Supplement 2 1998
Robert, A.H. 1997. Progestin-only oral contraceptive. The essentials of contraceptive technology. Saadatnia, M. & Tajmirriahi, M. 2007. Hormonal Contraceptives as a risk factor for cerebral venous and sinus thrombosis. Acta Neurologica Scandinavica 115(5) : 295-300.
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