Population control is one of the burning problems
facing India today.
While there are a plethora of contraceptive methods today
each one has its own drawbacks. The average doctor still has
many doubts about contraceptive methods, which have remained
the search for the perfect contraceptive continues. In the following section a
few of the problems that could face a practitioner are spelt out
with possible solutions.
Natural methods of
The natural methods are the
Rhythm method, the Basal body temperature method and the cervical
mucus method. The
rhythm method is the method commonly used. In this method intercourse
is avoided on possible days of ovulation. Ovulation is said to take
place about 14days+/- 2 days before the next period. The period of the second
half of the cycle between ovulation and the menstruation that
follows is more or less fixed.
However variations in the menstrual cycle are common in the
perimenopausal women, and at times of stress, travel,and medication.
Failure rates are high in the natural methods of contraception.
In India, “Today” is the most
popular vaginal sponge in use.
It is a soft disposable foam sponge made of
polyurethane. It has an
attached nylon loop which helps in its removal. It is moistened with
water, squeezed gently to remove excess water and inserted high up
in the vagina to cover the cervix. It acts for 24 hours and
intercourse may be repeated as often as desired during this
period. Failure rate
varies between 9 and 27 per 100 users in the first year. It must be removed and
thrown away after 8-24 hours but not before 6 hours of the last
Intrauterine contraceptive device
An IUD should be ideally be
inserted post menstrually, so that insertion in the early stage of
pregnancy is avoided. But a patient should not be refused
insertion at other times as she may get pregnant before the next
Postcoital: To prevent or
interrupt pregnancy following unprotected intercourse IUD’s have
been inserted up to 5 days after coitus.
Post-abortal: Studies in various
countries and by WHO showed no increased incidence of infection,
perforation, expulsion, bleeding or other events following insertion
of IUD after spontaneous or induced abortion. However, in patients
who can come for follow up, the author would prefer to wait for the
next cycle to insert an IUD.
In case the patient gets irregular bleeding after the
abortion, it may be due to endometritis/incomplete evacuation, but
with an IUD in situ, it becomes difficult to convince the patient to
continue using the IUD. s it may be prudent to wait for post abortal
events to settle before inserting an IUD.
partum: Both postpartum
and interval insertion after caesarian delivery have been found to
be safe and effective, but there is a higher expulsion rate. Most authorities advocate
insertion after 6 weeks of delivery. Following caesarian section
it is better to introduce IUD after 3 months of delivery.
Citrus bioflavonoid compounds
(Gynae CVP) in the dose of one capsule thrice daily or pure
synthetic diosmin (Venusmin) in the same dose may be useful. The author has found
proprietary ayurvedic uterine tonics useful in such cases.
Intermenstrual bleeding with IUD usually passes
off in a month and only reassurance is necessary.
following IUD insertion:
A careful pelvic examination should be done. If there is tenderness in
one of the fornices, there could be pelvic infection. The IUD should be removed
and antibiotics effective against both aerobic and anaerobic
infections like metronidazole and ampicillin or cephalosporins for a
course of 10-14 days is recommended. On examination, if the
thread of the IUD is not seen, an X-ray or an USG will confirm if
the IUD is correctly positioned. If it is not, a perforation
could have occurred and the IUD removed. If it is in position, and
on pelvic examination
there is no tenderness, the pain could be due to uterine cramps
which can be relieved with antispasmodics or NSAIDs. Even if there
is no history of amenorrhoea it is mandatory to do a urine pregnancy
test to rule out the possibility of ectopic pregnancy. If pregnancy test is
negative, pelvic infection should be looked for. and treated.. The
position of the IUCD should be checked to make sure it has not got
Since polymenorrhoea is
usually due to local inflammatory reaction, NSAIDs in the dose
usually used for ovulatory bleeding may be enough to cure it. This
will also take care of uterine cramps if they are the source of
lower abdominal pain. Bioflanoids (Gynae CVP) could be added. Iron
should be added to prevent anaemi
with IUCD in situ:
There is no evidence at all that
pregnancy is more likely than usual to result in an infant with
congenital malformations if IUD s including copper devices are left
in situ. Thus the IUD
need not be removed for fear of congenital malformations in the
foetus. But it should
be removed, as an ongoing pregnancy with an IUD in situ has more
chance of getting aborted or going into premature labour.
OC pills :
There is no increased risk of malformations in the
babies of women who become pregnanty while taking OC pills. If the woman desires to
continue pregnancy, she should be reassured and a pregnancy
termination should not be advised.
Quite often it is seen that when
a pregnancy test is shown as weakly positive and there is an ongoing
pregnancy, it may become strongly positive the next week. While the patient is waiting
for the matter to be settled, it is preferable to stop the pill and
use some other method of contraception.
Breakthrough bleeding on OC pills:
Breakthrough bleeding is usually due to low
oestrogen content in OC’s.
It may stop with continued use. If it is bothersome to the
patient, she could take 2 pills a day for 2-3 days after which she
can continue with her old dose. As an alternative, she can
be given 0.02 mg /day of ethynyl estradiol(2 tablets of Linoral
0.01mg) for 2 or 3 days in addition for 7 days along with the
pill. From the next
cycle onwards, she should be put on pills containing higher (0.05mg)
dose of oestrogen (e.g: Ovral,Duoluton,Mala N,Lyndiol) This may be
continued for at least 2 or 3 cycles.
Weight gain after continued
use of OC pills:
The oestrogen in OC pills may
cause oedema and progesterone may cause increase of tissue and fat
due to anabolic effects.
Triphasic pills (Triquilar) , pills containing Desogestrel
(Femilon,Novelon) may help in restricting weight gain due to their
lower androgenic and anabolic effects.
& breast tenderness.
Progestogen content of OC’s
actually reduces the risk of cancer. The patient should be informed
that by taking OC pills she is actually protecting herself from
breast cancer. The pain
caused by the oestrogen in the OC’s pass off with continued use and
wearing tight braissiers. The author has found pills containing
VitaminE in the dose of 600mg /day useful in cases of mastalgia.
Headache & OC pills:
Ovral-L contains a dose of 0.15mg
Norgestrel as the progestin component. Migraine is caused by the
oestrogenic component of OC-pills. Changing to a pill containing
higher progestogenic content may counter this effect. Changing over to
Primovlar,Ovral or Duoluton containing 0.25mg of Norgestrel may
help. If the symptom
does not abate, the pill may have to be stopped.
Ccontraindications to the use of
OC pills should not be used in
patients with Thromboembolism,Cerebrovascular accident, liver
adenoma. Gallbladder disease, cholestatic jaundice during pregnancy,
focal migraine, malignancy of the breast or genital tract, or if
surgery is contemplated within 4 weeks.
Hypertension,diabetes,Epilepsy,obesity,H/O past liver disease,
recent history of depression,sickle cell disease, hyperlipidemia,
age over 45, smoking above 35 years of age are relative
For women who do not accept oral
contraceptives or IUDs, there are injectable contraceptives
available in the market.
They contain progestogens. The two types of
progestogens only injectable contraceptives which have been well
tried are Depot medroxy progesterone acetate (DMPA) and
Norethisterone enanthate(NET-EN or Noristerat). 150mg NET-EN
injection given every 2 months is an effective regimen. WHO has also recommended the
dosage schedule of 200mg NET EN every 60 days for 6 months. It has to be given in the
first 5-7 days of the menstrual cycle. It has no bad estrogenic
side effects and does not inhibit lactation. The most common side effects
of the drug are irregular menstrual bleeding, spotting as well as
temporary stoppage of periods.
For women using it for short periods, these irregularities
may not be bothersome.
Proper counselling before administration can be helpful. Irregular and heavy bleeding
can be managed with 1.25-2.5mg conjugated estrogen for 7-21
days. Use of Oral
contraceptives in these cases is discouraged.
A combination of ethinyl
estradiol 0.1mg with 1mg of dl-Norgestrel repeated after 12
hours(i.e Ovral 2 tablets stat and after 12 hours) starting within
72 hours of coitus has a failue rate of only 0.16% Antiemetics may
be supplimented to prevent nausea. If high dose pills are not
available the low dose pills containg 0.03mg Ethinyl estradiol and
0.15mg l-Norgestrel (MalaD or Ovral-L) can be used.(4tablets stat
and after 12 hours) In
case of failure, there is no risk of teratogenicity to the
woman presents after 72 hours, IUD insertion is an effective
method. IUD’s inserted
within 5-7 days of unprotected intercourse has been found
useful. Due to the
higher chance of pelvic infection, it should be used cautiously in
women with multiple partners or victims of rape,
Contraception for the woman with
dose OCs : Low
dose oral contraceptives are safe in women with diabetes..
Compliance with insulin therapy and frequent medical evaluation are
important. As virtually all currently marketed oral contraceptives
contain a low-dose estrogen (0.030 to 0.040 mg), particular
attention should be paid to selecting the lowest progestin dose with
the least androgenicity, such as the monophasic NET preparations
containing 0.50 mg or less or triphasic LNG preparations (0.075 to
0.125 mg). Before initiating oral contraceptive therapy, baseline
monitoring of weight, blood pressure, glucose control (e.g., review
of home glucose monitoring, postprandial glucose, glycosylated
hemoglobin levels), and fasting lipids is recommended. After the
first cycle of oral contraceptive use and every 3 to 4 months
thereafter, weight and blood pressure must be monitored along with
glycemic control (postprandial glucose and glycosylated hemoglobin
levels). Because diabetic patients tend to exhibit elevated serum
triglycerides, which may be exacerbated by an estrogen dominant oral
contraceptive, a follow-up measurement of serum lipids at 3 to 6
months may be performed. Thereafter, unless indicated, lipid levels
can be obtained annually. Along with encouraging good glycemic
control via diet and medical therapy, the importance of maintaining
ideal body weight and engaging in a daily moderate exercise program
should be stressed and discussed at each visit.
pill:Progesterone only minipills or
progesterone depot preparations are other alternatives.
Physicians are skeptic about IUD
insertion in the diabetic woman due to their increased
susceptibility for pelvic inflammatory disease. Proper aseptic
techniques and the use of antibiotics during insertion can minimise
this risk.. The greatest risk for pelvic inflammatory disease
associated with IUD use occurs during the first 4 months after
insertion. Antibiotic prophylaxis at time of insertion may be of
benefit in reducing postinsertion infection and probably should be
considered. Recommended antibiotics include doxycycline (200 mg
prior to insertion and 100 mg 12 hours later), erythromycin (500 mg
prior to insertion and again 6 hours later), or azithromycin (500 mg
prior to insertion). The procedure should be delayed
if bacterial vaginitis/cervicitis or pelvic tenderness is detected
until a cause is established and the symptoms resolved. A 4 to 6
weeks postinsertion examination allows the detection of infection
and identifies explusions.