Introduction

Contraceptives may be classified into Modern and Traditional Methods.

Modern and traditional methods of contraceptives are illustrated in the following table

Modern Methods of Contraception	Traditional Methods of Contraception
Condoms;	Withdrawal
Hormonal Contraceptives like oral pills and injectable;	Breast feeding
Intra uterine contraceptive device (IUD);	Rhythm Methods
Implants;
ontraceptive Surgery (tubal ligation & vasectomy)

The modern methods of contraception can further be sub-classified into temporary methods and permanent method. The temporary methods of contraception include

• Condoms;
• Hormonal Contraceptives;
• Intrauterine contraceptive device; and
• Implants.

The permanent methods of contraception include

Contraceptive surgery, which consist of

• Tubal Ligation for women; and
• Vasectomy for men.

The following section discusses the modern methods of contraceptives on the following lines:

• Types of contraceptive;
• Benefits;
• Limitations;
• Indications;
• Contraindications;
• Side effects and Management;
• Danger Signs.

Condoms

Types of Condoms

Condoms are thick sheath made of rubber (latex), vinyl or natural (animal) product, which may be treated with a spremicide for added protection.

How to Use a Condom

You or your partner should put the condom on the penis as soon as the penis is erect.

• Place the unrolled condom on the tip of the penis; then rill the condom all the way to the base of the penis. Compress the tip of the condom when putting it on so that it is not filled with air. The tip must be empty to receive semen, otherwise the condom may burst;
• After ejaculation, the man should pull his penis out of the vagina before completely losing his erection; Hold the rim of the condom to the base of the penis so it will not slip off.
• Take off the condom without spilling semen on the vaginal opening; and
• Throw the used condom away in a pit latrine, bury it or put in a packet and throw in a dustbin.

Indications

Condoms are appropriate for the following:

• Couples who need a method immediately;
• Couples who have a partner with more than one sexual partner;
• Women / Men at risk for STDs; and
• Couples who have intercourse infrequently.

Condoms prevent sperm for gaining access to female reproductive tract and microorganisms from passing from one part to another.

Benefits

Condoms have the following benefits:-

• No method related health risks;
• Effective immediately;
• no medical supervision required;
• Inexpensive;
• Available outside the health care system;
• Public examination not required prior to use;
• May prolong erection and time to ejaculation;

Limitations

• High failure rate;
• Latex and vinyl condoms (but not natural) provide protection against STDs;
• Not advised for clients at high risk for pregnancy;
• User dependent;
• Re-supply must be available;
• Supplies must be readily available before intercourse occurs;
• Adequate storage may not be available at client¡¯s home; and
• Proper disposal of used condom may be a problem.

Combined Oral Contraceptive Pills

Combined Oral Contraceptive Pills (COCs) are small pills, which contain two synthetic hormones, estrogen and progestin, which are very similar to the hormones that are naturally present in the woman¡¯s body.

COCs are available in packets of 28 pills. Twenty-one white pills are hormone pills, which are to be taken once daily from the first day of the menstrual period and the remaining seven are brown iron pills, which are to be taken once the brown pills are finished. Once the packet is finished, the next packet should be started the very next day.

Benefits

• Very effective when used correctly (efficacy is as high as 99.9%);
• Decreased menstrual cramps;
• Regular menstrual periods most months;
• Decreased benign breast diseases (fibrocystic changes)
• Decreased problems with ovarian cysts;
• Decreased risk of cancer of the ovaries and ovarian cysts;
• Decreased risk of cancer of endometrium (lining of uterus);
• Decreased risk of ectopic pregnancy; and
• Improvement of acne (in some women).

Limitations

• Does not protect against STDs;
• Must be taken every day; and
• Minor side effects.

Indications

• Desire a highly effective method of contraception (99.9% effective when used correctly);
• Has anemia from heavy menstrual bleeding;
• no medical supervision required;
• Has severe menstrual cramping;
• Complains of menstrual cycle symptoms like premenstrual weight gain, anxiety, depression, mid cycle ovarian pain;
• Long history of irregular menstrual cycle;
• Has a history of ectopic pregnancy;
• Has had benign ovarian cysts; and
• Strong family history of ovarian cancer.

Contra-indications

1. Pregnancy;
2. Breastfeeding to a child less than 6 weeks of age;
3. Unexplained vaginal bleeding;
4. Jaundice / Hepatitis;
5. Smoker and age 35 years or older;
6. Women with diabetic history of more than 20 years;
7. Migraine;
8. Hypertension;
9. Breast cancer;
10. Liver tumors;
11. Epilepsy; and
12. Tuberculosis.

Side Effects & Management

Side Effect	Management
Amenorrhea	Assess how you have been taking your pills; Have you missed any pill; Check for pregnancy; If not pregnant then continue taking COCs;.
Bleeding / Spotting	If the you have recently begun using COCs, then do not worry; otherwise check for gynecological conditions; The spotting / bleeding settles by fourth month of start of COCs
Hypertension	If BP is more than 160/100 then, discontinue, otherwise slight raise in BP settles in 1-3 months.
Nausea / Dizziness / Nervousness	Find out if pills are taken in morning or on an empty stomach. Take pill with evening meal or just before bed time; Check for pregnancy; If no cause found, this situation will decrease over the first 3 months of COC use.
Breast fullness or tenderness	Check for pregnancy; Check breasts for Lumps / Cysts; Discharge; Discuss with your service provider if you feel uncomfortable with breastfullness or tenderness..
Chest Pain (especially if it occurs with exercise)	Check for possible cardiovascular disease and check for blood pressure and heart for irregular beats (arrhythmias) with your service provider.
Depression	May be related to progestin in COCs. If your depression has worsened while using COCs, choose another method.
Headache	If headaches are mild, take analgesics (paracetamol / aspirin). Consult your service provider to re-evaluate after 1 month if mild headache persists; If headaches have changed since starting COCs (i.e., associated with numbness, tingling, or loss of speech, blurred vision), stop COCs and choose another method.
Jaundice	Acute jaundice occurring after starting COC use begins is not method related. Check for Hepatitis, Gall Bladder Disease & benign or malignant tumors. If jaundice is due to hepatitis, gall bladder disease or liver tumors, stop COC and choose another method.

Danger Signs

If the following signs appear, this should be taken as an emergency situation and the woman taking oral contraceptives should be taken to a hospital immediately.

• Severe lower abdominal pain
• Severe headache
• Loss of or blurred vision
• Severe chest pain, shortness of breath
• Severe leg (calf or thigh) pain
• Slurred speech

Injectables

• They cause cervical mucus to become too thick for sperm to pass through;
• They suppress ovulation; and
• They cause the lining of the uterus to become less rich in blood vessel and unprepared for an egg to implant.

Benefits

• Very effective (Efficacy is 99.6%);
• Long acting;
• Effective even if the client is a week late for her return visit;
• Offer privacy to user;
• May help decrease anemia;
• Appealing to those whole shots better than pills;
• Do not significantly affect breast milk supply or quality;
• Nothing to remember beyond returning for follow up visit;
• Does not interfere with sexual intercourse;
• Useful for women who want no more children, but prefer not to have sterilization;
• Useful for women over 35 years of age;
• Provides some protection against pelvic inflammatory disease; and
• Do not have the serious heart and blood clotting effects.

Limitations

• Do not protect against STDs;
• Since they are long acting, can not be easily discontinued or removed from the body; and
• The injectable contraceptive for three months may worsen diabetes but the one that is for two months has no effect on glucose tolerance and hence is the better option for women with diabetes;

Indications

• Injectable may be an appropriate method for a woman who:
• Prefers a contraceptive which does not require action either before intercourse or every day;
• Is breast feeding and needs and wants a contraceptive;
• Already has two or more children, but does not want a permanent method;
• Has had estrogen related side effects from combined oral contraceptive including vascular headaches (migraine), nausea, high blood pressure or breast tenderness; and
• Has sickle cell disease.

Contraindications

• Pregnancy;
• Unexplained vaginal bleeding;
• Jaundice;
• Breast cancer;
• Epilepsy;
• Tuberculosis;
• Women who can not remember to take pills every day;
• Uncontrolled Diabetes Mellitus
• Hypertension of 160/100 or more;
• Sever headaches; and
• Depression;

Side Effects & Management

Side Effect	Management
Amenorrhea	Check for pregnancy. If ruled out, continue with injectable;
Bleeding / Spotting	Examine for genital tract lesions such as vaginitis, cervicitis, cervical polyps or uterine fibroids. Continue and if you are not satisfied, two treatment options are recommended: Take a cycle of COCs; or Ibuprofen up to 800mg 3 times daily for five days;
Amenorrhea	Evaluate Genital Tract abnormality, if not found supplement with a cycle of COCs; or Ibuprofen up to 800mg 3 times daily for five days;

Danger Signs

• Severe lower abdominal pain
• Severe headache
• Loss of or blurred vision
• SHeavy or prolonged vaginal bleeding;

Intra-Uterine Contraceptive Device (IUCD)

Intra uterine contraceptive device (IUCD) are placed in the uterus to interfere with fertilization. IUCDs are highly effective with an efficacy between 97%-99%. With an IUCD in place, the transport of sperm and eggs through the fallopian tubes are altered, preventing fertilization. It also causes the destruction of sperm and egg, secondary to inflammatory changes in the uterus.

• TCopper Multi-Load 375 whose life span is for 5 years; and
• Copper CuT 380 A, whose life span is for 10 years.

Benefits

• IUCD is a safe, easy to use, reversible, effective method of child spacing for couples with at least one child;
• Breast-feeding women can safely use iUCDs;
• IUCDs can be good choice for women with oral contraceptive pills precautions;

Limitations

Intra uterine contraceptive device (IUCD) are placed in the uterus to interfere with fertilization. IUCDs are highly effective with an efficacy between 97%-99%. With an IUCD in place, the transport of sperm and eggs through the fallopian tubes are altered, preventing fertilization. It also causes the destruction of sperm and egg, secondary to inflammatory changes in the uterus.

• Not advised for women with out any children;
• Poor insertion and removal practices in clinics put client and practitioner at risk of serious infections, including pelvic inflammatory diseases, HIV and Hepatitis B; and
• Does not prevent STDs.

Indications

• Sensitive to hormonal contraceptives; and
• Want long-term spacing.

Contraindications

• Pregnancy;
• Unexplained vaginal bleeding;
• Cervical Cancer;
• Endometrial, Ovarian cancer;
• Pelvic Inflammatory Disease;
• Hydatidiform mole;
• Anatomical Abnormalities;
• Severe Dysmenorrhea; and
• Iron Deficiency Anemia.

Side Effects & Management

Side Effect	Management
Amenorrhea	If you are over 45, amenorrhea could be related to menopause; If you are not pregnant, continue using IUCD;
Irregular Bleeding	Evaluate for pelvic infection, pain or tenderness, palpable mass or enlarged uterus
Cramping	Assess for pelvic inflammatory disease. If not found and cramping is not severe, continue otherwise get the IUCD removed and choose another method.
Pelvic Infection	If abdominal and pelvic examination including microscopic examination supports diagnosis of pelvic inflammatory disease, get IUCD removed and take antibiotics.
Vaginal Discharge	Assess for history of STDs. If found positive get treated accordingly and get IUCD removed only in cases of strongly suspected or diagnosed gonorrhea or chlamydia.

Danger Signs

• Period Late;
• Abdominal pain
• Infection
• Not feeling well, fever chills; and
• String missing, shorter or longer

Implants (Norplant)

Implants commonly also called Norplant[1] is a set of 6 small, plastic capsules. Each capsule is about the size of a small matchstick. The capsules are placed under the skin of the woman¡¯s upper arm.

Each capsule contains a progestin, similar to a natural hormone that a woman¡¯s body makes. It is released very slowly from all 6 capsules. The implant contains no estrogen. A set of implants can prevent pregnancy for 5 years.

Benefits

• Very effective (Efficacy ranges from 91% to 99.9%);
• Long-term pregnancy protection but reversible;
• Nothing to remember. Requires to daily pill taking or repeated injections.
• Effective within 24 hours after insertion;
• Fertility return is quick;
• Quantity and quality of breast milk do not seem harmed. Can be used by nursing mothers starting 6 weeks after childbirth;
• No estrogen related side effects; and
• Helps prevent ectopic pregnancy.

Implants commonly also called Norplant[1] is a set of 6 small, plastic capsules. Each capsule is about the size of a small matchstick. The capsules are placed under the skin of the woman¡¯s upper arm.

Each capsule contains a progestin, similar to a natural hormone that a woman¡¯s body makes. It is released very slowly from all 6 capsules. The implant contains no estrogen. A set of implants can prevent pregnancy for 5 years.

Limitations

• Common Side effects;
• Client cannot start or stop use on her own. Capsule must be inserted and removed by specially trained health care provider;
• Discomfort for several hours to 1 day after insertion for some

bleeding	Get evaluated and manage accordingly
Unexplained abnormal vaginal bleeding	Continue, it will settle with time
Sever pain in lower abdomen	Get evaluated and treat accordingly
Pain after insertion of capsules	IGet evaluated and take ibuprofen
Infection at insertion site or abscess present	Take oral antibiotics for 7 days
Ischemic Heart Disease	If develops after the insertion, get the implant removed
Severe headaches	If headaches have worsened after insertion of implant, get it removed

Female Sterilization

Female sterilization provides permanent contraception for women who do want any more children. It is a safe and simple surgical procedure. Proper infection prevention procedures are required. Female sterilization is also known as voluntary surgical contraception (VSC), tubal ligation, tying the tubes, minilap and ¡°the operation¡±.

Benefits

• Very effective;
• Permanent;
• Nothing to remember. No supplies needed and no repeated clinic visits required;
• No effect on breast milk; and
• Helps protect against ovarian cancer.

Limitations

• Un common complications of surgery;
• requires physical examination and surgery by a specially trained provider;
• Reversal surgery is difficult and not available in most areas; and
• No protection against STDs.

Indications

• Indications
• Contraindications
• Pregnancy;
• Active Pelvic Infection; and
• Acute Systemic infection.

Side Effects	Management
Wound Infection	Treat with antibiotics
Post operative fever	Determine source of infection
Bladder, intestinal injuries	Determine presence of blood in urine or other signs of internal injury
Hematoma	Determine presence of infection or abscess
Gas embolism (very rare)	Check for increased respiration and pulse, decreased BP
Pain at incision site	Determine presence of infection or abscess
Superficial bleeding	Determine presence of infection or abscess

Vasectomy

Vasectomy provides permanent contraception for men who decide that they do not want any more children. It is safe, simple and quick surgical procedure. It can be done in a clinic with proper infection prevention procedures. It does not affect sexual ability.

Benefits

• Very effective;
• Permanent;
• Nothing to remember except to use condoms or another effective method for the first 20 ejaculations or the first 3 months, whichever comes first;
• Does not affect a man¡¯s ability to have sex; and
• No supplies to get, and no repeated clinic visits required.

Limitations

• Common minor short term complications of pregnancy;
• Requires minor surgery by specially trained service provider;
• Not effective immediately. The first 20 ejaculations after vasectomy may contain sperms. The couple must use another contraceptive method for the first 20 ejaculations or the first 3 months after surgery ? whichever comes first;
• Reversal surgery is difficult, expensive and not available in most areas of the world; and
• No protection against STDs.

Indications

• Appropriate for couples certain they want no more children; and
• Age or health problems of wife ? might cause high-risk pregnancy.

Contraindications

• Local skin or scrotal infection;
• Genital infection;
• Large varicocele;
• Inguinal Hernia;
• Filariasis; and
• Previous scrotal surgery

Side Effects	Management
Wound Infection	Confirm presence of infection or abscess
Hematoma	Determine presence of infection or abscess
Granuloma	Check for possible problem like infection, hematoma
Excessive Swelling	Check for possible problem (infection, hematoma)
Pain at the incision site	Check for infection, granuloma or epididmitis

Emergency Contraception

Emergency contraception should be taken within 72 hours of unprotected sexual intercourse. These are very effective (<3% failure rate) but should be taken only in the form of an emergency but not as a regular method of contracption.

Instructions

Take 4 tablets of combined oral contraceptives within 72 hours after unprotected sexual intercourse followed by 4 more pills in 12 hours. Hence, in total you have to take 8 pills in 12 hours.

Side Effects:

• Nausea ( temporary, may last for a day or so);
• Vomiting ? if within 1 hour after taking first or second dose of COCs, client may need to repeat the drug dose.

Contraceptives Price Charged By Ministry of Population Welfare

S.No.	Contraceptive Method	Price Charged (Pak Rs.)
1	Condom (Per Unit)	Rs 0.50
2	Oral Pill (Per Cycle)	Rs 3.00
3	IUD (Per Unit)	Rs 3.00
4	Injection (Per Unit)	Rs 3.00