Temporary Modern Contraceptive Methods

Short Acting Contraceptive

Short Acting Contraceptives are a category of contraception methods which are highly effective in protecting against unplanned pregnancies. To make them work best they have to be used in short time intervals from single use (e.g. the condom), daily intake (e.g. the pill) to up to 3 monthly application (e.g. injectable contraceptives).

Condom: A condom is a barrier device commonly used during sexual intercourse to reduce the probability of pregnancy and spreading sexually transmitted diseases.

• Male Condom

Male condoms are more common than female ones. A condom is a thin barrier contraceptive device which is worn on the male penis to prevent sperm intervention into the woman's vagina during intercourse. Condoms come in different types and thicknesses.

Condoms can be made of different material; latex, polyurethane plastic, etc. Also, condoms come in different colors and sizes, thicknesses and styles. They can be dry, lubricated, they can be used with spermicidal. Condoms should be stored in a dry, protected from light place, and in such conditions they can be stored for 5 years.

Benefits

• Affordability, ease of use
• Effectiveness in preventing sexually transmitted diseases (AIDS, syphilis, gonorrhea, chlamydia, herpes virus, HPV, hepatitis B)

Side effects (allergy to latex) are rare

• The method does not require special skills and involvement of medical staff

Limitations

• It is necessary to plan the sexual intercourse in advance
• Condoms sometimes can torn
• There are cases of latex allergy in men and women (you can use condoms made of polyurethane)
• Inability to use in case of insufficient erection
• Condoms may reduce the sensitivity of sexual intercourse for one or both partners
• It is not possible to use condoms with oil-based lubricants as they reduce their strength

Management

• In case the condom breaks
  • Discard and and use new condoms
  • Use a spermicide with condom
  • Instruct client to be careful until her next menstruation
  • Instruct the client to take emergency contraceptives

Special Instructions

• The condom is rolled down over the penis when it is erected.
• When the man ejaculates, it prevents the sperm from entering the woman's vagina.
• The condom also prevents that you become infected with sexually transmitted diseases.
• Once ejaculation has occurred, the condom must be removed.
• When removing the penis from the vagina, a man should hold the condom, and then dispose it off.
• A man should be careful that semen from the condom will not get into the vagina.
• After each intercourse the condom should be thrown away.
• Condoms can not be reused so new condom should be used for each sex.
• Precautions should be taken while using condoms because sometimes it may break so extra condom should be made handy.

Rumors and Fact about Condom

• False Rumor: The condom may come off and get stuck in the vagina.
• Fact: This is very unlikely, but if it does happen the condom can be removed easily with the fingers.
• False Rumor: The condom may burst during intercourse.
• Fact: This rarely happens if put on correctly. (see client instructions for handing of condom.)
• False Rumor: Condom decrease sexual pleasure.
• Fact: In fact condom can increase ssexual pleasure as condoms can prevent premature ejaculation.
• False Rumor: Men only use condoms with prostitutes.
• Fact: Condoms are widely used throughout the world among married couples.
   
• Female Condoms

A female condom is an inserted into the vagina tube made of polyurethane or similar elastic material with a diameter of about 8 cm and a length of about 18 cm with tighter rings on both ends of the condom, one of which is inserted into the vagina like a diaphragm and the other one remains outside.

Benefits

• Use of the female condom does not depend on erection of the penis.
• It can be left on for 10 hours in the vagina, in contrast to the male condom which must be removed immediately after intercourse.
• When used properly, it reliably protects against pregnancy and STD.
• The outer end covers a significant part of the external genitalia, which provides additional protection.
• Method of application is simple but requires some training.
• Due to the lack of data it is not possible to certainly say how well the female condom can protect against pregnancy.
• No contraindications.
• Female condoms can be used by people with allergy to latex, as they are also polyurethane manufactured of.

Limitations

• High price and rarity.
• Condoms of nitrile polymers have a pretty strong odor when you remove them from the packaging. However, it is not resistant disappears. and quickly.
• The female condom is large, it is not easy to introduce, it is not attractive and may slip.
• When using this type of condom, there may appear unpleasant sounds.
• There is insufficient lubrication. For this reason, female condoms are often sold together with a lubricant.
• Oral contraceptive pills Combined Oral Contraceptives (COCs) .

The combined oral contraceptives (COCs) pill is one of the most reliable reversible methods that can be provided beyond the health post where most people live in Nepal. Although COCS have been available in Nepa since the early 1970s their use still romains low. 

Type of Combined Oral Contraceptives (COCs)

In Nepal the most common COCs are low dose pills in 28 day package There for there names and composition are as follows:

• Gulf: It contains menstranel (estrogen) 50 mcg and norethindrore (progesterone) 1 mg the brownish tablet contains 75 mg of ferro-S sulphate.
• Nilocan: It contains ethinyl estradiol - 35 microgram a-c norethindrone 0.5 mg. Progesterone is less so the side effects a less in Nilocan.
• Lo-femenal: Available at all HMG facilities which contains norgestrel (progestin) 0.3 mg and ethinyl estradiol (estrogen) 0.03 mg in each pill. (0.01 mg = 1 mcg) The last 7 brown placebo pills contain 75 mg ferrous sulphate (Iron)
• Sequential Estrogen: It is given alone for 14 to 16 days beginning on the 5-7 days of the menstrual cycle and followed by a tablet containing estrogen and progesterone during the next 5 to 7 days.
• Micro Pills: (Progesterone only) They are given in a low dose for 30 days, even during menstruation. A small dose of progesterone does not interfere with pituitary hypothalamic ovarian functions.

Benefits

• Very effective with correct use (<1 pregnancy per 100 woman-years)
• Do not interfere with intercourse. Easy to discontinue at any time.
• Non contraceptive health benefits. Available at health facilities and medical shops.
• Does not require pelvic exam to use few method related side effects. - Low cost
• Make menstrual cycle regular and cure dysmenorrhea.

Limitations

• Must be used correctly to be most effective.
• Require daily/correct use and regular resupply.
• Less appropriate when breast feeding. Do not prevent STI/HIV AIDS, HBV.
• Some during interactions (rifampicin for TB medications for for seizure disorders)
• Amenorrhoea
• Minor side effect may be seen as: -
• Spotting between period, irregular heavy bleeding. - Breast tenderness
• Weight gain
• Nausea
• Headache

Mechanisms of Action

• Suppress ovulation: These pills prevent pregnancy by suppressing ovulation (Pre, venting release of eggs from the ovary)
• Family Planning Programme.
• Reduce sperm transport in upper genital tract (fallopian tubes).
• Change endometrium (alteration) making implantation less likely.
• Thinker cervical mucus (preventing sperm penetration).

Effectiveness

Combined oral contraceptives are an oral extremely effective temporary method of family planning. Combined contraceptives are 99.9% effective when used correctly. They are more effective than the condoms, or spermicidal suppositories. Actual user effectiveness is lower, a first year failure rate is 1-3% because they are frequently incorrectly a inconsistently. used

• Mood changes.
• Dizziness.
• Fluid retentions, high blood pressure in a few women.
• Possible decreased milk secretion if initiating breastfeeding.

Health Benefits

• Decreased Incidence of:
  • Endometrial cancer.
  • Ovarian cancer.
  • Entopic pregnancy.
  • Acute pelvic inflammatory disease.
  • Anemia.
  • Benign breast disease.
  • Endometriosis symptoms.
  • Dysmenorrhoea.
  • Some women may gain weight.
  • COCS appropriate especially for women.

WHO want a highly effective method of contraception and are willing to take pills daily.

• Have irregular cycles.
• Have anemia especially due menstrual bleeding. to

Contraindication

• Venous thrombosis.
• Severe hypertension.
• Absolute contraindication.
• History of cholestatic jaundice pregnancy.
• Confirmed pregnancy.
• Undiagnosed vaginal bleeding.
• Obesity.
• Varicosities - Epilepsy.
• Depression and fluctuation of the mood. Age over 35 years.
• Smoking more than 15 cigarettes/per day. Breast feeding mother less than 6 months.

Precautions

• Pregnancy (suspected)
• Jaundice (active symptomatic hepatitis) Heavy smoking and over age of 35.
• Migraine headaches with focal neurological symptoms.
• suspected breast cancer.
• Current or past history of venous thromboembolic disorder. Moderate- severe hypertension. Current or Cancer/suspicious breast lumps. Undiagnosed vaginal bleeding.
• Other conditions requiring precautions.
• Long term use of anticonvulsants and rifampicin. Breast feeding less than 4 months postpartum.
• When to Start COCS.
• When it is reasonable to believe client is not pregnant (No signs or symptoms or pregnancy) and:
• No intercourse since last normal menses.
• Correct and consistent use of reliable method.
• Within 6 weeks postpartum (Non- breastfeeding) or Within four months postpartum (breast feeding) or - Within first 7 days post abortion or immediately.
• Common side effects.
• Break through and other bleeding Irregularities.
• Nausea.
• Weight gain - Headache.
• Mood changes.
• Breast tenderness.
• Acne and Pigmentation.
• Client Instructions: Warning signs
• Abdominal (lower) or pelvic pain (severe)
• Chest pain, cough, shortness of breath (sever) - Headache
• Eye problem (Vision loss or blurring) - Severe leg pain (Calf or thigh)
• If client experiences any of these side effects she should return to see the service provider.
• Instruction for the use of COCS
• The client should take one pill each day, preferably at the sometime of the day.
• Start taking pills within the first seven days of the menstrual cycles.
• Start with the pill in the top left hand corner of the packet and continue taking the next pill one day each, until all the white pills are gone (for 21 days) and then start the brown pills taking one pill each day for 7 day until all are gone. No Rest Period
• When she begins to take the pills, she may have some inter menstrual bleeding. This light bleeding is not her menstrual period and is not dangerous and will disappear after one or two packs of pill. She should continue taking the pill each day.
• She may have some side effect nausea dizziness, headache because he, body is adjusting to the pill. Thes
• persist; she should
• discomforts come back to the clinic.
• When the 28 day packet is empty, she should start taking pills from a new packet the next day. She should take the pill evening meal. at bedtime or with the
• Instruction for missed pills
• If she misses one or more pills she is at risk of becoming pregnant.
• If she forgets 1 pill. Take it as soon as she remembers- continue packet of pills as usual.
• If she forget 2 or more pills. Take 2 pill a day until she catches up continue packet of pills as usual. - Use back of method condoms or not have sex for 7 days.
• Instruction for menstrual periods
• If she misses two or more menstrual period she should come to the health clinic check to see if she is pregnant.
• Pills and medical care
• She should bring the pills packet with her to each return visit. Normally clinics supply pills for 3 months.
• If she forgets 1 pill. Take it as soon as she remembers- continue.
• She should mention about taking pills anytime she makes visit to a health care provider.

Injectable Hormones

Depo-Provera

The only injectable contraceptive available in Nepal is depot-medroxy progesterone acetate or DMPA. The brand name for such of the DMPA currently available in Nepal is Depo-Provera commonly called 'Depo Sangini', 'Teen mahiney sui'. It comes in a single dose vial containing 150 mg (1 ml)

Counseling for DMPA

Counseling is an ongoing process that is a part of all aspects of family planning services. Counseling does not take place at only one time in the provision of family planning services, instead, counseling techniques are used and family planning is given and discussed information is given and throughout the process of a clients choosing and receiving a specific family planning method. Counseling enables a client to make a voluntary informed choice.

Mechanism of Action

• Thicken cervical mucus (Preventing sperm penetration).
• Reduce sperms transport in upper genital tract (fallopian tubes).
• Change endometrium implantation less likely.
• Suppress ovulation.

Benefits

• Highly effective (over 99%)
• Rapidly effective (< 24 hours)
• Easy to use (eg: women may make the decision to use DMPA or her own)
• Can provide long term protection.
• Pelvic exam not required to begin use.
• Few method- related health risks since there is no estrogen.
• Does not interfere or sexual desire.
• Convenient: Only action required of used is to go for her injection every 3 months.
• No supplies needed by client.
• Effectiveness continues even if the client is up to 2 weeks late for her return visit.
• Does no adversely affect breast feeding.
• Reversible
• Can be used by older women (over 40)
• Useful for women who want no more children, but prefer not to have sterilization.
• May be used by post abortion clients.
• Limitations Does not protect against most STI, including HIV/AIDS.
• Causes menstrual changes in most users.
• Amenorrhea in 50-80 percent of users.
• Irregular bleeding, including spotting.
• Possible delay in return to fertility after discontinuation.
• Must return to the health post for injections or attend a DMPA mobile outreach clinic if possible.
• Client cannot discontinue the method on her own before next injection.
• Weigh gain a common side effect (may not be a disadvantage for many clients).
• May cause depression

Health Benefits

• Decreased acute pelvic inflammatory diseases.
• May improve iron deficiency anemia.
• Protects against endometrial cancer.
• Reduce the risk of ectopic pregnancy.
• May increase the amount of breast feeding women:
• May reduce pre menstrual symptoms (discomforts monthly period).

Timing of Injection

DMPA may be given at any time during the menstrual cycle; provided it be determined that the client is not pregnant. Optimal times for giving the first DMPA injection are:

• During menstruation: within seven days from the onset.
• Post partum: When post partum
• Mother brings brings her infant for
• Immunizations (6 week postpartum)
• Post abortion: Immediately or within the first seven days.
• Breast feeding amenorrhea and less than 6 month postpartum (LAM).
• The first injection can be delayed until one of the following occurs:
• Her menses return.
• She begins to supplement her baby's diet.
• Her baby is 6 months old.

Dication for Use

Women of any reproductive age or parity who:

• Desire effective, reversible method.
• Cannot take estrogen.
• Are breastfeeding (six weeks or more postpartum)
• Are post abortion.
• Com raindication for use
• The only absolute contraindication for the use of DMPA is: known or confirmed pregnancy.
• The most important counseling point for potential and current DMPA users is that they should expect some change in their menstrual cyce. They are:

Side Effects

• Prolonged bleeding/bleeding for more days than a women would normally (ie. during the first month of use)
• Bleeding or spotting between periods (during first few month d use)
• No bleeding at all (5% after one year of use)
• Headache/dizziness
• Change in weight (both increase and decrease usually not more then 2 kg)
• Breast tenderness/ discomfort.

Precaution for Use

• Suspected pregnancy.
• Unexplained vaginal bleeding.
• Precaution should be taken before giving DMPA to a woman who has:
• Active liver disease or liver tumors.
• Breast lumps or known or suspected breast cancer.
• Other problems requiring precautions:
• Diabetes.
• Severe vascular or migraine headache.
• Depression.
• Women unable to accept change in their menstrual cycle.

Rumors and Facts

False Rumor: DMPA/Depo-Provera causes woman to be weak and less able to work.

Fact: 90 million women have used the method in many countries. DMPA does not appear to cause weakness. In fact, DMPA may protect women from anemia which causes weakness.

False Rumor: DMPA/Depo-Provera will cause very heavy bleeding.

Fact: Very heavy bleeding is quite unlikely; what does happen is that DMPA may cause cause frequent and irregular light bleeding. This usually 

subsides in a few months when a woman will actually be more likely to have no menstruation bleeding at all.

False Rumor: DMPA/Depo-Provera will cause loss of appetite and weight loss.

Fact: Actually, the opposite has been found to be more common: women using this method often gain some weight (2 kg in the first year).

False Rumor: DMPA/Depo-Provera causes breast milk to dry up.

Fact: It is actually the reverse; DMPA, if anything, causes an increase in breast milk. DMPA is very safe to use by breastfeeding mothers after 6 weeks of delivery. A mother may start DMPA even if her menstruation has not resumed.

False Rumor: Women who use DMPA need a rest period from time to time.

Spermicides

Foam Tab

Foam tab commonly available in Nepal is "Kamal Chakki". Foam contraceptives are spermicides inserted inside a woman's vagina before sexual intercourse. They are used to kill sperm and prevent sperm from reaching the egg. Foam contraceptives can be effective if used properly (according to the product's instructions).

Mechanism of Action

It cause the sperm cell membrane to break which decreases sperm movement (mobility) and their ability to fertilise ovum.

Benefits

• Foam contraceptives are easily accessible and can be bought over the counter in drugstores
• They are inexpensive compared to birth control pills, Depo Provera and other forms of birth control
• Women don't need a prescription or doctor's permission to buy foam spermicides
• Foam contraceptives are both safe and effective
• Do not have to worry about the side effects of hormones (hormones aren't used).
• Women unlike other forms of birth control, women don't have to wait for hours for it to take effect.
• Women who are breastfeeding can also use foam contraceptives, because they are hormone-free.

Limitations

• A common complaint against foam contraceptives is vaginal irritation and infections
• Some women experience allergic reactions to spermicidal foams which can cause burning, redness itchiness or
• Some women experience discomfort when inserting the foam inside their vagina
• Women who have sensitive skin shouldn't use foam contraceptives.
• Women needs to have practice to put the foam into the vagina It has to be put every time during sex
• It cannot be use if the partner has spermicide allergy
• Doesnot protect against STIs and HIV

Side Effects

• Rare side effects may include:
  • Itching.
  • Burning when you urinate.
  • Pain.
  • Increased white discharge.

Management

• A slight inflammation of the vagina.
• The management for the side effects of spermicides is the use of another contraceptive method.
• Special instructions while using spermicides.
• Wash hands with soap and water before inserting the tablet.
• Foaming tablets should be moistened with water before being placed in the vagina.
• Insert the tablet in a lying down position by holding it with the middle and fore finger. (nowadays applicators are used).
• Tablet should be inserted deep inside the vagina till it reaches the cervix.
• Foam spermicides should be used with a condom to decrease the risk of STIS. When using condoms with foam spermicides, check expiration dates on condoms and and don't condoms. 

Jelly and Pastes

Jellies, creams & gels are all chemical contraceptives, or spermicides. Most of these drugs not only provide a contraceptive effect, but also protect against genital infections.

Mode of Action

The mode of action of the spermicidal chemicals is based on substances that kill sperm and hinder its penetration into the uterus. Creams, jellies and gels start to act immediately after their introduction in the vagina, and the effect lasts for 1 hour.

Benefits

• The main advantage of creams, jellies and gels is the fact that a woman doesn't have to wait 10-15 min before having sex as with suppositories. Creams, jellies and gels are immediately distributed to the inner walls of the vagina and begin to act.
• Contraceptive creams, jellies and gels add additional lubrication during sexual intercourse, so their use may be very relevant for those couples who experience a problem with dry vagina.
• It contains antibacterial ingredients and protect the body from mild infections.
• Contraceptive creams, gels and jellies are recommended for women who lead irregular sexual life or have any contraindication to the use of other contraceptives.

Limitations

Can sometimes cause itching or burning.

Side Effect

Continuous use of spermicidal creams, jellies or gels on a regular basis, destroy the healthy micro flora of the vagina and cause vaginal dysbacteriosis.

Special Instructions

• Creams, jellies and gels introduced in the vagina either by hand or by a special applicator.
• The spermicidal properties last within an hour after the insertion of
• the contraceptives it is necessary to remember if you want to continue to enjoy sex.
• Do not forget that after the intercourse you should not use soap, but warm water only.

Mechanical Methods

Diaphragm

For the first time the diaphragm made of rubber, was introduced in 1883 by a German scientist C. Hasse. In the future diaphragms gained popularity not only in Germany but also abroad. After 100 years there was launched an improved model of the diaphragm with a soft fringe made of latex and rim ensuring tight contact with the walls of the vagina.

Modern diaphragm is a domed cap made of rubber or latex, with a flexible, springy rim. There are several types of diaphragms, differing in the structure of the rim. Each type is available in size from 50-55 mm to 95 mm.

A diaphragm should be renewed after 2-3 years.

Indication

• In combination with the rhythm method of contraception
• Temporary method of contraception during a break in the use of oral contraceptives or IUD
• Local contraception in women with a reduced risk of pregnancy (with rare sexual contacts reproductive period) or in late

Contraindications

• High risk of pregnancy
• Allergy to rubber, spermicides, latex
• Endocervicitis
• Cervical erosion
• Suspicion on or presence of malignant transformation of the cervix
• Colpitis
• Toxic shock syndrome in the history
• Female genital abnormalities
• Vaginal prolapse
• Recurrent urinary tract infectionsBenefits Ease of use and affordability
• Possibility of multiple use
• It can be inserted some time before intercourse.
• Prevention of cervical cancer (when used for 5 years and over), as well as sexually transmitted diseases
• When the diaphragm is correctly in place, neither the woman or the man can feel it.

Limitations

• Relatively low contraceptive efficacy
• Due to low efficiency, it does not eliminate the fear of an unwanted pregnancy
• The need of simultaneous use of spermicides, as well as manipulations in the vagina right before the sexual intercourse

Side Effects

• Allergy
• Urinary retention
• Discomfort in a woman and / or sexual partner because of the diaphragm rim pressure
• Recurrent vaginal candidiasis
• Recurrence of inflammatory diseases of the internal organs
• The woman's risk of having cystitis is increased.

Special Instructions

• Diaphragm should always be used together with spermicide.
• The diaphragm is lubricated with spermicide on both side
• Choose a comfortable position either sitting on the edge of chair or lying down or squat or standing with one foot on chair
• Separate the lips of vulva with one hand and pinch the rim of diaphragm to fold it in half with the other hand
• Place index finger in the center of the diaphragm and push it as far up and back in the vagina as possible.
• If it takes more than two hours from the diaphragm has been placed until intercourse a new portion of spermicide should be applied.
• It is not necessary to take out the diaphragm since the spermicide can be inserted directly into the vagina as a suppository or with a syringe.
• Diaphragm should be left in for 6 to 8 hours after the lat act of intercourse.
• While removing hook a finger over the top of the rim to break the suction and pull it down and out
• After use, it should be washed with mild soap and warm water
• The diaphragm should regularly be checked for holes.

After

After having sexual intrecourse

• Wash your hand.
• Hook a finger over the top of the rim to break the suction.
• Pull the diaphragm down and out.

Cervical Cap

The cervical cap is a type of barrier contraception method used to prevent unwanted pregnancy. It is a silicone cap shaped like a tailor's thimble that is inserted into the vagina and fits over the cervix.

Mechanism of Action

Cervical caps works by blocking the opening of uterus and thus prevents pregnancy by keeping sperm away from joining with the the ovum. Some of the latest cervical caps are covered with spermicide cream or jelly which stops the movement of sperm cells.

Cervical caps should not be used in:

• History of allergic reactions silicone or spermicides used cervical caps.
• Pain syndrome while touching vulva or vagina.
• Giving birth in the last 3 month.
• Vaginal breaks or cuts.
• Cervical caps should not be used during vaginal bleedings of any kind including bleedings during periods,
• History of surgery on the cervix.
• Weak vaginal muscle tone.
• History of toxic shock syndrome.
• History of abortion.

Benefits

• It can be used during breastfeeding.
• It can be inserted even 6 hours before sexual intercourse.
• It does not affect hormonal system.
• It immediately effective reversible.
• It is not felt by women or men.
• Easy portable.
• Safe, simple contraception method.
• Cervical caps can not be used during menstruation.
• It is not convenient for some women to insert.
• Can be pushed out by some penis size.
• Cervical caps containing spermicidal may irritate vaginal tissue.
• It needs to be inserted each time before sexual activity.
• It needs to be in place all the during during sexual intercourse

Side Effects

• Usually most women can use cervical caps without any problem. However, some women may experience some side effect. In rare cases women using cervical may experience the following side effects:
• Vaginal irritation can be a sign of allergic reaction to spermicide.
• Pain or discomfort during sexual discomfort in men and women.
• Burning sensation during urination.
• Uncomfortable in the vagina when cervical cap is inserted.
• Vaginal spotting or bleeding.
• Itching in the vagina.
• Redness and swelling of the vagina and vulva.

Special Instruction

• To increase the effectiveness of cervical caps is important to make sure the cervix is covered before each sexual intercourse and spermicide is used.
• The sexual partner can make cervical caps more effective by using condoms or pulling out before ejaculation.
• Unfortunately, cervical caps do not protect from sexual transmitted diseases. It is needed to use latex condoms to decrease the risk of infections.