The role of contraception in family planning and women\

The role of contraception in family planning and women's reproductive health protection

НазваThe role of contraception in family planning and women's reproductive health protection
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Family planning is an important stage in woman's life, that provides the birth of only desirable children. Our country has a high rate of artificial abortions, that during many years has traditionally been the main method of family planning. Proceeding from complications, that occur after artificial abortions (inflammatory processes in organs of small pelvis, infertility, interrupting of pregnancy, bleeding, anomaly of labour activity, one-third of maternal death rate causes), decreasing of abortions amount can greatly influence on obstetric and gynecological morbidity and decrease the level of maternal death-rate.

One of the ways of abortions' rate decreasing is wide application of contraception agents. Questions about contraception should be developed not only by family planning centres, that recently are widely opening in Ukraine, but also by district doctors and midwives. Sanitary-educational work concerning this question can be held by medical nurses, that's why they have to know this problem. Application of contraceptive agents has an important role for public health service of women especially in reproductive age because some of them (preservatives, vaginal contraceptives) give a possibility to prevent sexually-transmitted diseases — gonorrhoea, chlamidiosis, mycoplasmosis, myxoplasmosis, gardnerellosis, herpetic and cytomegalovirus infection, in the development of which the infectious factor is of great importance. While propagandising contraceptives, the medical specialists have to explain, that they have no negative influence on birth-rate, they only prevent abortions.

The choice of contraceptive agent is made with taking into consideration plenty of factors — non-contraceptive properties, that can be used for improving woman's health and prophylaxis of some diseases, method's effectiveness, its safety, and also individual attitude of the woman to contraceptive agent. Woman should be in detail informed about advantages of this or that contraceptive, about indications and contraindication to application of the contraceptive agent. Woman's knowledge and possibility of her own choice increases effectiveness of the method. The effectiveness of any contraceptive agent is expressed by Perl's index, that is determined by amount of pregnancies per 100 women, that have used this method during a year.

Hormonal, intrauterine, barrier, surgical and postcoital methods of contraceptives are distinguished.

Hormonal contraception

With aim of hormonal contraception such agents are used:

  • combined (estrogen-gestagenic) oral contraceptives

  • gestagenic oral contraceptives (mini-pills)

  • prolonged injective contraceptives

  • implant contraceptives

According to international statistics oral hormonal contraceptives are used yearly by a great number of woman (from 100 to 120 mln.) in the world.

There exist single-component contraceptives, which contain only progestagen and combined oral contraceptives. ^ Combined oral contraceptives (COC) are very effective agents, that contain estrogenic and gestagenic component. Nowadays there are about 500 kinds of COC, that differ in phase, dosage and gestagen type.

In monophase preparations (Marvelon, Mersilon, Microgynon, Minisyston, Sylest, Femoden) all the pills have identical composition. Logest is a low-dosed contraceptive (20 mkg ethinyl estradiol, or 75 mkg of gestogen), that has high reliability of contraception, good tolerance, supports body weight stability. Diane-35 (Cytoproterone acetate/ethinyl estradiol) is a monophase combined oral contraceptive with antiandrogenic action. It belongs to this group of medecines also.

^ Combined diphasic (Antyovin) contraceptives have a permanent dose of estrogens and different doses of progestagenic component in different phases of the cycle.

Three-phase preparations (Triquilar, Tri-regol) contain pills of three different ingredients, that differ in dosage of estrogen and progestagenic components.

^ Mode of action of all COC is identical and does not depend on the phases of preparation, dosage and type of progestagen, that is included in the preparation structure:

  • inhibition of FSH and LH synthesis by hypophysis and inhibiting of LH ovulatory peak. On background of COC reception during 21 day there is no lifting of endogenous estrogens and progestagens, FSH, LH level

  • a progestagenic component makes cervical mucus more viscous and impassable for sperm

  • the mosaic changes in endometrium make implantation of impregnated ovum imppossible. This, all in all, is conditioned by action of progestagenic component of COC. Although, such contraceptive effect is potentiated by identical dose of estrogen, which contains a pill. Only during 7-day interruption after 3-weekly application of COC there can be mentioned ovarian and pituitary activity

  • also COC contribute to decreasing of menstrual bleeding (for duration and amount of lost blood), menstrual pain, they reduce the risk of some inflammatory diseases organs of small pelvis

  • one can refer to disadvantages the pathological states that sometimes accompany to COC reception. First of all, this is insignificant nausea, change of body mass and psychoemotional sphere (headache, giddiness, worsening of mood, libido). One should remember, that effectiveness of COC can be decreased simultaneous reception of some drugs (anticonvulsants, antituberculous)

  • COC are prescribed after abortion (or during 7 days after it) and in three weeks after delivery, if woman does not breast-feed. As a rule, hormonal oral contraceptives are used in those cases, when action of estrogenic component of hormonal contraceptive is undesirable (for example, for smoking women, which, have violation of fibrillation properties). It is necessary to remember, that patients, which recently have had cerebral stroke, should not use only progestagenic pills, except cases, when more optimum contraceptive agent is inaccessible or unacceptable

Advantages: high effectiveness, application simplicity, reversibility, presence of favourable action on reproductive function and female organism as a whole. A regular and long (not less 2 years) reception of COC considerably reduces frequency of malignant diseases of uterus and uterine adnexa, development of mastopathy and postmenopausal osteoporosis.

^ Contraindications to application of COC are pregnancy, vascular pathology at present or in the past (hypertension, trombophlebitis, IHD), smoking at the age over 35 years, disease of liver with its dysfunction, hormone-dependent tumours, bleeding of unknown etiology, expressed obesity.

^ Application schemes. Monophase pills are usually used from the 1st day of menstrual cycle with 7-day interruption. During the usage of phase pills their reception must coincide with cycle phase. One can delay menses on 3 weeks if she takes the monophase preparations without break. Analogical situation can be induced by three-phase preparations, if to use from the next packing (after completion of previous one reception) pills of the third phase. In this case a bleeding will be delayed on 7-8 days. If there is the necessity to prolong the term of menses delay, then after reception of three-phase preparation one can at once proceed to reception of monophase preparations, and bleeding delay will continue up to the 21st day.

In case of violation of pills' reception rule's contraceptive action guarantee decreases. It is necessary to remember, that if one omits the reception of a pill less than for 12 hours, one should at once take the skipped pill. If more then 12 hours have passed, a woman has to ingest a pill and to use the additional methods of contraception during 7 days. Moreover if no more than 7 days remain to completion of packing, there is no need to make a 7-days interval. One should proceed to the following packing at ones. If 2 and more pills are omitted, a woman has to stop reception of the agent for 7 days and continue with the new packing. A woman taking COC, has to be examined every 3 months, then — in half a year, and then — once yearly.

^ Gestagenic oral contraceptives. Composition of these pills does not include estrogens, but progestins only in dose of 1 mg or less as derivates of Nortesto-sterone, Linoesterol, Ethynnodiole-diacetate, Exlutone.

The effectiveness of gestagenic oral contraceptives is higher in women of older age. As in combined contraceptives, extraordinary important sense has keeping to preparations reception rules.

These agents give a positive effect in case of painful and excessive menses, mastalgia, premenstrual syndrome. One of the major advantages there is that gestagenic contraceptives can be used during lactation.

Mode of action:

  • anovulation due to lutropin production suppression

  • change of cervical mucus, that prevent penetration of spermatozoa into the uterus

  • changes in endometrium, that do not create optimum conditions for implanting

  • change of contractile activity of uterine tubes, that prevent fecundating process

  • influence on spermatozoa and their vital functions

Indications: intolerance to estrogens or presence of side effects, for women aged 35, for smoking women during the lactation period, people sick with essential hypertension, diabetes mellitus.

Contraindication: pregnancy, severe diseases of cardiac-vascular system in present or in anamnesis, dysfunction of menstrual cycle of unknown etiology, state after hydatiform mole.

^ Rules of reception: the pills are taken from the 1st day of menstrual cycle definitely in the same time in uninterrupted mode.

When there is lateness with reception of pill for more than 3 hours, omitting of the next pill reception, presence of vomiting or diarrhea, at reception of the pill there are necessary additional preventive measures.

So, the gestagenic contraceptives have a limited application, however in some cases they can be the agents of choice.

^ Prolonged contraceptives for injections. Combined estrogen-gestagenic injective contraceptives (CIC) — Cyclofem, Mesigyna, and one-component injective contraceptives, to the structure of which progestagens of prolonged action are included — Depot-medroxyprogesterone acetate are distinguished. Depo-provera are the most widespread contraceptives in this group.

Mode of action:

  • prevents ovulation due to suppression of gonadotropic hormones secretion

  • causes changes in cervical mucus

  • causes changes in endometrium, that prevent the ovum implantation

Advantages of prolonged contraceptives: high effectiveness, absence of estrogen-depended side effects, fast and long contraceptive effect, possibility of using during lactation.

During application of this agent some positive non-contraceptive effects are observed: decreasing of blood loss during menses, reduction of menstrual pain, and also prophylactics of endometrial and ovarian cancer. At the same time it is necessary to keep in mind the agent's defects — impossibility of quick withdrawal of its action, delay of fertility renewing till 6-12 months, frequent disorders of menstrual cycle.

Contraindications: pregnancy, disorders of menstrual cycle of unknown etiology, intolerance to the agent.

^ Relative contraindications are: liver diseases with its dysfunction, thromboembolism states, diabetes mellitus.

Application rules. Depo-provera are injected every 3 months. The first injection is made in first 5 days of menstrual cycle or 6 weeks after delivery. The following injection is CIC usage is made every month. When only progestagen IC is used the following injection is made in every 2-3 months.

In case of appearing of bloody discharge during 1-2 cycles COC can be used in addition. At continuation of bleeding it is necessary to examine the patient on the presence of organic pathology.

Recently gestagenic implanting agent "Norplast" is used, which contains an active substance laevonorgestrel. This preparation in appearance of capsules is implanted subcutaneous. It provides the contraceptive effect during 5 years.

^ Advantages of this method: continuity and long duration of contraception, fast renewing of fertility after moving away of capsules; positive non- contraceptive action on the organism typical for gestagens.

Mutual side effects are found, as a rule, during first months of contraception: galactorrhea, insignificant weight-gain, lowering of libido, tiredness, irritability.

Contraindications: pregnancy, breast cancer, bleeding of unknown etiology.

Intrauterine contraception (IUC)

Mode of action: decreases activity and viability of spermatozoids, reinforces spermicidal activityof endometrium, decreases ovum viability term, gives rise to antiperistalsis of uterine tubes. Emissive copper-bearing (Copper T 380 A, Nova T, Multiload 375), and emissive progestines IU devices (IVD) (Progestasert, Levo Nova) are distinguished. IUD Gaine-T 380 Similine has high contraceptive reliability. The Perl's index is 0,31 per 100.

In case, if fecundating has taken place, change of tubal peristalsis and contractile uterine activity, change of metabolic processes in endometrium, violation of secretory transformations in endometrium prevent coming of pregnancy.

Hormones-containing IUD, besides, cause hormone-conditioned contraceptive effects (Mirena).

^ Contra-indications for IUC. Absolute: pregnancy, oncologic pathology of uterus or its cervix, uterine bleeding of unknown origin, infections of genital tract. Relative: ectopic pregnancy in the past, presence of several sexual partners.

In case of presence of uterine fibroid tumor, IUC can be a method of choice.

^ Barrier methods of contraception

Male condoms, vaginal diaphragms and cervical caps, spermicides belong to the barrier methods of contraception.

Mode of action of barrier contraceptives: they create mechanical obstacle for Sperm getting into vagina (the condom) and cervix (the cap) neck, inactivate the sperm.

Recently there have appeared the new types of barrier contraceptives that contain hormones. Spermicides exist in different forms — creams, gels, vaginal foam tablets, sponges, films (gynofilm).

^ Advantage in using barrier methods is that they in some way prevent to spreading of sexually-transmitted infections. The condoms, made from latex, have high effectiveness as for prevention from AIDS and hepatitis B virus infecting.

Rhythm method of contraception

It is based on avoidance of coitus for 3 days before and 3-4 days after expected ovulation is in its base. For determination of ovulation they use basal temperature test and infertility scale are used.

Surgical contraception

Nowadays in many countries of the world this is a widely spread method of contraception. Effectiveness of contraception of this method reaches 100%.

Female sterilization is made by means of tubal laparoscopic cautery, and the male one — by means of ligation of the section of vas deferens. Disadvantage of this method is in its inreversibility.

Postcoital contraception

It is used in case, when coitus was not protected by other methods of contraception. They use COC — 2-4 pills within 72 hours of intercourse, twice in 12 hours (10-12 mg of ethinyl estradiol per 1 dose).

Danazol is ingested during the first 72 hours 600 mg twice in 12 hours.


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