7-Chapter I

Chapter I Contraceptive methods used during
lactation
Chapter I
Contraceptive methods used
during lactation
It is well accepted that breastfeeding contributes significantly to

child survival and child nutrition. Healthful child spacing is associated with
improved birth outcomes and maternal recovery. On a population basis,
breastfeeding may contribute more to birth spacing than all family planning
use combined in many countries. However, while breastfeeding does provide
a period of infertility, until recently, there was no reliable way for an
individual woman to capitalize on this lactational infertility for her own
efficacious child spacing (Labbok et al., 1994).
Adequate postpartum contraception is recommended in order to

prevent mother and infant morbidity. The mother-infant benefits of lactation
are well recognized, and exclusive, regular and frequent breastfeeding is an
effective contraceptive method for amenorrheic patients. However, the
resumption of fertility varies among women and access to health services is
not guaranteed in many regions of the world. Short interpregnancy intervals
increase maternal and fetal complications and therefore effective postpartum
contraception is imperative. The ideal method prescribed should be effective
and safe, i.e., should not interfere with lactation or alter the hemostatic
system. During the postpartum period, ideally non-hormonal methods should
be used because they do not alter lactation or hemostasis. However, in
populations with difficult access to health or with an early start of calorie
supplementation to the newborn, the option should be for progestogens-only
8
lactation
contraceptives, ideally initiated after six weeks or earlier in special situations

(Vieira et al., 2008).
The available contraceptive methods are:
1- Hormonal contraception will be presented in two parts:
- Progestin only contraceptives: progestin only pill, implants and

injectables.
- Combined oral contraceptives “the pill”.
2- Intrauterine device.
3- Condoms.
4- Spermicides and vaginal barrier methods.
5- Natural methods: Abstinence and coitus interrupts.
6- Fertility awareness methods:
- Calendar method.
- Basal body temperature.
- Cervical mucus method.
- Symptothermal method.
7- Voluntary surgical contraception.
9
lactation
(A) Lactational Amenorrhea Method (LAM)
Background and Biological Basis:
In 1988, researchers from several centers around the world met to

share their findings at the Rockefeller Bellagio Conference Center, and
agreed that three criteria could be sufficient to predict fertility return. These
findings were then presented to a group of family planning service providers
at Georgetown University, resulting in the codification of LAM as a family
planning method (Labbok et al., 1994).
LAM has three criteria:
1. Amenorrhea:
Defined as the absence of the menses. Menses return is defined as

the first two sequential days of bleeding or spotting which may occur after
two months postpartum (Labbok et al., 1994).
2. Less than six months postpartum (Labbok et al., 1994).
3. Fully or nearly fully breastfeeding:
Both the frequency and intensity of breastfeeding reduce the

chance of pregnancy. Frequent, continuous stimulation of the breast by
around-the-clock stickling strengthens the reflex stimulation that produces
the contraceptive effect. It has been suggested that a minimum number of the
breast feeding episodes, such as 6 per day, might be sufficient for protecting
against pregnancy. Effective suckling patterns can consist of:
10
lactation
(1) Few suckling episodes per hour (less than 1 per hour) each lasting at
least 11 minutes OR
(2) A higher frequency of suckling episodes per hour (about 5) each
lasting only about 3 minutes (Fathalla et al., 1990).
A reduction from full breastfeeding to breastfeeding supplemented

with other foods greatly raises the probability that ovulation will resume
(Fathalla et al., 1990).
Efficacy:
The effectiveness of LAM has been demonstrated in clinical trials

and in programmatic use. As long as all three criteria are met, the method is
about 98%-99% effective (perfect use). If any one of the criteria is unmet,
the use of another method which is appropriate for use during breastfeeding
should be recommended for continued high pregnancy protection. The
method allows deviation from the three criteria without a sudden increase in
risk of unplanned pregnancy. Menses return is the least flexible. If a woman
is no longer amenorrheic, she cannot use LAM (Labbok, 2000).
If a woman has deviated only slightly from the fully or nearly fully
breastfeeding criterion, she should be re-counseled about appropriate
breastfeeding and may use LAM thereafter if she returns to nearly fully
breastfeeding. Small amounts of other food or liquid which do not replace
breastfeeds do not have a substantial effect on the woman's fertility.
However, lowered frequencies of breastfeeding and regular supplementation
11
lactation
to the infant's diet are associated with an increased risk of menses return and
a higher probability that ovulation will precede that menses (Labbok, 2000).
If an amenorrheic woman is separated from her infant and

expresses milk, she may still use LAM. Milk expression by hand or pump
may produce sufficient breast stimulation to prevent ovulatory activity.
However, her risk of pregnancy is increased to 5 to 6% (Labbok, 2000).
A Cochrane literature review on efficacy in 2003 was carried out

using MEDLINE and EMBASE search from 1966-2002, as well as other
publications and data sources on lactational amenorrhea. Thirteen
publications, reporting on nine intervention and two control groups, met the
inclusion criteria. The reviewers concluded that LAM is a viable
contraceptive method, available and accessible to many women. Life table
pregnancy rates at 6 months among LAM users ranged from 0.45 to 2.45
percent. Life table pregnancy rates of women fully breastfeeding and
amenorrheic but not actively using LAM or other contraceptive methods
were 0.88 in one study and 0.9-1.2 percent in a second study, depending on
the definition of menstruation used. The life table menstruation rate at 6
months ranged from 11.1 to 39.4 percent in these studies and included
women who exclusively breastfed for various lengths of time (Van der
Wijden et al., 2003).
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lactation
Optimal Breastfeeding Behaviors for Child Health and

Child Spacing:
• Begin breastfeeding as soon as possible after the child is born.
• Breastfeed exclusively for the first six months.
• After the first six months, when supplemental foods are introduced,
breastfeeding should precede supplemental feedings.
• Breastfeed frequently, whenever the infant is hungry, day and night.
• Continue breastfeeding even if the mother or the baby becomes ill.
• Avoid using a bottle, pacifiers or other artificial nipples.
• Eat and drink sufficient quantities to satisfy the mother's hunger.
• Continue to breastfeed up to two years and beyond (Labbok et al.,

1994).
Mechanism of action:
Breast-feeding still prevents more pregnancies than all modern

forms of contraception in many developing countries. Afferent neural inputs
from the nipple pass via the spinal cord to the hypothalamus, where they
cause a local release of beta endorphin. This acts to depress Gonadotropin
releasing hormone (GnRH) secretion, thereby inhibiting pituitary
gonadotrophin secretion, ovarian follicular development, ovulation and
menstruation. The hypothalamic beta endorphin release also inhibits
13
lactation
dopamine production, resulting in increased pituitary prolactin secretion.

The higher the suckling frequency is, the more beta endorphin that is
released and hence the longer the duration of lactational amenorrhea (Short,
1993).
Extended LAM:
LAM may be appropriate beyond 6 months or if the infant is

supplemented, as long as she breastfeeds intensely. The 6-month limit for
LAM exists primarily because infant diets need to be supplemented after that
time to ensure continued growth and development and to avoid iron-
deficiency anemia. Cumulative pregnancy rates during lactational
amenorrhea (regardless of whether the infant received supplementary food)
at 6 and 12 months are 2.9% and 5.9%, respectively, compared with 0.5% at
6 months for LAM (Hatcher & Kowal, 2000).
Conclusions:
Breastfeeding is best for both mothers and babies and should be

encouraged. Breastfeeding can also provide natural, safe, effective
contraceptive protection, if certain conditions are met, for up to six months
postpartum. Women who are interested in using the natural protection of
breastfeeding should have access to information about LAM and about other
available family planning methods suitable for breastfeeding women
(Labbok et al., 1994).
14
lactation
(B) Intrauterine Devices (IUDs)
IUDs are devices inserted into the uterine cavity to prevent

pregnancy; they provide reversible long-acting contraception with high
efficacy and safety (Toppozada, 1995).
IUDs cause formation of a ”biological foam" within the uterine

cavity that contains strands of fibrin, phagocyte cells and proteolytic
enzymes (Berek & Novak, 2007).
Copper IUDs (Cu IUDs) continuously release a small amount of

the metal producing an even great inflammatory response. All IUDs
stimulate the formation of prostaglandins within the uterus, consistent with
both smooth muscle contraction and inflammation. Scanning electro
microscope studies of the endometrium of women wearing IUDs show
alteration in the surface morphology of cells, specially the microvilli of
ciliated cells. Major alterations in the composition of proteins within the
uterine cavity and new proteins and proteinase inhibitors have been found in
washings from uterus containing IUD. The altered intrauterine environment
interferes with sperm passage through the uterus, preventing fertilization
(Berek & Novak, 2007).
Effectiveness:
The use of IUDs is highly effective in preventing pregnancy and it

is also very cost-effective. It is one of the most popular methods of
contraception in the world today. More than 80 million women are using
15
lactation
IUDs for contraception worldwide, and its effectiveness rivals that of tubal
sterilization (Population Reports, 1995 & Peterson et al., 1996).
The first-year failure rate in typical IUD users is 6%. The lowest
expected / reported pregnancy rates in medicated IUDs are 1% and 0.5%
respectively, and among non-medicated IUDs the percentages are 2% and
3%, respectively. The rates may be lower for newest generation of copper
and progestin IUDs (Hatcher et al., 1998).
Prevalence of IUDs use in developing countries:
Currently, the mix of available methods has greatly expanded and

the IUDs are the second most prevalent form of contraception used world
wide, after female sterilization, with prevalence rates of 13.6% and 20.5%
respectively, among women of reproductive age, married or in union. Thus
the IUDs are the most commonly used reversible method globally. However,
there is a notable difference between the developed world, where it is used
by 7.6% of these women, and the developing world where this proportion is
almost doubled at 14.5% (United Nations, 2006).
The variety of country situations with regard to IUD use can be

explained by a number of factors at the individual, service delivery, program
and policy levels (Sullivan et al., 2006).
In Egypt, a National Commission on Population was created in

1953. In 2003, IUDs were used by 36.7% of Egyptian women aged 15-49,
married or in union, or 63% of contraceptive users (Chiou et al., 2003).
16
lactation
IUDs with high copper content are the most cost-effective methods
currently available (Newton & Tacchi, 1990).
Mechanism of action:
IUDs have become widely used since their introduction, but their
specific contraceptive action is far from clear. The mode of action of the
IUD is important, since if the IUD is an abortifacient, it could have
important moral, religious, and ethical repercussions. However, it is
generally believed that all IUDs stimulate an inflammatory response in the
uterus (Newton & Tacchi, 1990).
In women using an IUD, sensitive assays for human chorionic

gonadotropin (hCG) provide evidence of implantation in 1% of menstrual
cycles (O'connor et al., 2007).
In 1997, a review suggested that effects that occur after fertilization

are an important mechanism of action in all types of IUDs (Spinnato, 1997).
But this conclusion was disputed for Cu IUDs (Sivin, 1997 -

Mishell, 1997 - Mastroianni, 1997).
Since this time, at least three reviews have suggested that the
contraceptive effects of the Cu IUD occur predominantly before
fertilization (Mishell, 1998 - Rivera et al., 1999).
Understanding the mechanisms of action of the IUD in humans is

important for fundamental biomedical knowledge. It also provides key
17
lactation
information for clinicians who work with patients who may object to forms
of birth control that act after fertilization (Spinnato, 1999).
The possible prefertilization mechanisms of action of the IUD

include the following: inhibition of sperm migration and viability at the
level of the cervix, endometrium, and tube; slowing or speeding the transport
of the ovum through the fallopian tube; and damage to or destruction of the
ovum before fertilization. Hormonal evidence indicates that the IUD does
not generally inhibit ovulation in humans (Ortiz et al., 1996).
The majority of women who are wearing hormonally active IUDs

that reduce or eliminate menstruation still have ovulatory cycles as assessed
by hormonal measurement and follicular ultrasonography (Lahteenmaki et
al., 2000).
The possible postfertilization mechanisms of action of the IUD

include the following: slowing or speeding the transport of the early embryo
through the fallopian tube, damage to or destruction of the early embryo
before it reaches the uterus, and prevention of implantation (Standford &
Mikolajczyk, 2002).
The altered intrauterine environment interferes with sperm passage

through the uterus, preventing fertilization. The natural progesterone in the
progestasert induces endometrial atrophy. The levonorgestrel in the Mirena
is much more potent than natural progesterone. Blood levels of the
hormones are about half that seen with the levonorgestrel subdermal implant
(Norplant) and are sufficient to block ovulation in many women (Sivin,
1992).
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lactation
Sperm transport through the cervical mucus and the

endometrium:
Cu IUDs raise the copper concentration of cervical mucus

substantially and this has been shown to inhibit sperm motility. In contrast to
cervical mucus, there is abundant evidence for endometrial changes that are
likely to be to some degree spermicidal, inhibiting sperm migration through
the endometrium for all types of IUDs. The higher inflammatory response of
the endometrium in the presence of Cu IUD suggests that Cu IUDs may
have stronger spermicidal effects on the endometrial level (Morton et al.,
1992).
The fertilized ova in the oviducts of the IUD users are not found
explained by: Spermatozoa may not be able to reach to the site of
fertilization or they may not be able to penetrate the oocyst covering
(Morgenstien et al., 1996).
Biochemical evidence for fertilization:
The earliest available biochemical marker of fertilization in

humans in vivo is Early Pregnancy Factor (EPF). EPF is not unique to
pregnancy but it can be detected as early as 1 to 2 days after fertilization and
continuing through most of the pregnancy as long as it remains viable
(Morton et al., 1992).
A rigorous examination of the evidence on the mechanism of

action of IUDs indicates that both prefertilization and postfertilization
effects are significant contributors to the clinical efficacy of all types of
19
lactation
IUDs. Although prefertilization effects are more prominent for the Cu IUD,
both prefertilization and postfertilization mechanisms of action contribute
significantly to the effectiveness of all types of IUD. Patients considering
use of the IUD should be made aware of the available data about its
mechanisms of action (Standford & Mikolajczyk, 2002).
Duration of use:
In 1997, the World Heath Organization (WHO) published the

results of an international multicentre trial on the use of CuT IUDs up to 12
years (WHO, 1997).
Several other studies have confirmed the validity of extending the

use of the CuT 380A IUDs up to 10 years (Leynger & Yyengar, 2000).
Types of IUDs:
There are four types of IUDs approved by the Food and Drug
Administration (FDA). Three of these IUDs release copper and one type
releases progesterone. In 1988, the copper T380A (CuT 380A) was first
marketed in the USA for consumer. This device has a T-shaped plastic frame
with a 300 mm² surface area on the vertical stem and a 40 mm² copper collar
on each horizontal arm for a total of 380 mm² of copper surface area (Paul
et al., 1997).
The CuT 380A and the levonorgestrel T have remarkably low

pregnancy rates, less than 0.2 per 100 women years. Total pregnancies over
a 7 year period were only 1.1 per 100 for the levonorgestrel T and 1.4 for the
CuT 380A in a comparative study (Anon, 1997).
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lactation
Today, two IUDs are approved for use in the USA: a copper-
releasing device (ParaGard) and a hormone-re1easing device (Mirena). Both
IUDs have monofilament threads that minimize the risk for bacterial
transmission (Johnson, 2005).
Fig. 1: Types of IUDs (Speroff & Darney, 1992).
Non-contraceptive benefits:
With the exception of progestin or progesterone-releasing IUDs,

which tend to decrease menstrual blood loss and dysmenorrhea, IUDs have
relatively few non-contraceptive advantages. IUDs can prevent adherence of
the two walls of the uterus by synechiae (Asherman’s syndrome) (Treiman
et al., 1995).
21
lactation
IUDs are appropriate for:
(1) Breast feeding women.
(2) Women who have had at least one child..
(3) Women who want reversible contraception to space births or limit

family size (Townsend, 1991).
Possible Contraindications:
a) Absolute Contraindications:
(1) Active, recent or recurrent pelvic infection (acute or subacute), including

known or suspected gonorrhea (Varney et al., 2004).
(2) Pregnancy (known or suspected) (Varney et al., 2004).
b) Strong Relative Contraindications:
(3) History of ectopic pregnancy (Varney et al., 2004).
(4) Undiagnosed, irregular or abnormal uterine bleeding (Varney et al.,

2004).
(5) Risk factor for PID:
● Post partum endometritis.
● Infection following an abortion that occurred in the past three months.
● Purulent cervicitis until controlled.
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lactation
● Impaired response to infection (diabetes, steroid treatment).
● Recurrent history of gonorrhea.
● High risk factor for STDs (Varney et al., 2004).
(6) Risk factors for exposure to the human immunodeficiency virus (HIV)
(Varney et al., 2004).
(7) Cervical or uterine malignancy (known or suspected), including

unresolved Pap smear (Varney et al., 2004).
(8) Impaired coagulation response (idiopathic thrombocytopenic purpura,

anticoagulant therapy) (Varney et al., 2004).
c) Other Possible Relative Contraindications:
Including valvular heart disease, which may make the patient

susceptible to subacute bacterial endocarditis, (some clinicians recommend
prophylactic antibiotics), anatomical difficulties such as an abnormal shape
(leiomyomata, endometrial polyps, bicornuate uterus) cervical stenosis or a
small uterus, menstrual disorders such as severe dysmenorrhea, severe
menorrhagia or endometriosis, anemia, history of impaired fertility in a
woman who desires a future pregnancy history of fainting and allergy to
copper or diagnosed Wilson’s disease (Varney et al., 2004).
IUD insertion:
An IUD can be inserted any time during a woman’s menstrual

cycle unless a possibility exists that she may be pregnant. If pregnancy is a
23
lactation
possibility, delay the IUD insertion until the next menstrual flow which
usually indicates that the woman is not pregnant (Petersen et al., 1991).
Misoprostol facilitates insertion of an IUD, and reduces the number

of difficult and failed attempts of insertions in women with a narrow
cervical canal. The optimal regimen of Misoprostol remains to be defined
(Sääv et al., 2007).
Immediate post partum insertion of IUDs:
If labor and delivery were normal, the uterus is firm, and bleeding
has subsided, an IUD may be inserted. Manual post partum IUD insertion
immediately following delivery of the placenta is a safe, convenient
approach to birth control and carries no increased risk of infection,
perforation or bleeding. To minimize infection, use a sterile long-sleeved
glove (Hatcher et al., 1998).
A major drawback can be high expulsion rates. The chance of

expulsion can be minimized if you:
• Insert IUD within 10 minutes of delivery of the placenta.
• Remove blood clots digitally from the uterus.
• Manually place the IUD in the uterine cavity.
• Place the IUD high in the fundus (Hatcher et al., 1998).
24
lactation
The popularity of postpartum IUD insertion in countries as China,

Mexico and Egypt support the feasibility of this approach early follow up is
important in identifying spontaneous IUD expulsion (Grimes et al., 2002).
Insertion Technique:
The arms of the IUD are to be folded into the insertion tube far
enough to retain them. The physician should stabilize the cervix during the
insertion of the IUD with a tenaculum. A sterile uterine sound should be
used to determine the depth of the uterine cavity. An adequate uterine depth
is 6-9 cm. An IUD should not be inserted if the depth of the uterus is less
than 6 cm. The physician should then insert the IUD into the uterus unti1l
the flange is against the cervical os. The clear inserter tube should be pulled
back on the insertion rod approximately 2 cm so that the arms can spread to
the T position. The physician should remove the insertion rod by holding the
insertion tube in place and then remove the insertion tube and tenaculum.
Finally, the threads emerging from the cervical os should be cut to a length
of 3 cm (Johnson, 2005).
T- Shaped IUD accommodates its position in the uterine cavity

during the first 3 months following insertion, and that ultrasound evaluation
of its position is not a good predictor of future evolution (Foundes &
Perdigao, 2000).
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lactation
Fig. 2: Withdrawal technique (Speroff & Darney, 1992).
Side Effects and Complications:
(1) Spotting, bleeding, haemorrhage and anemia:
Following insertion of an IUD, there is almost always a certain

amount of bleeding. This is so common that women should be reassured that
26
lactation
it is a normal reaction to the insertion. Intermenstrual bleeding, usually in

the form of spotting, or a serosanguinous discharge, may occur during the
weeks after insertion. This amount of bleeding should not lead to removal of
the device unless it continues for more than two or three months
(Brueggemann, 1997).
The first few menstrual periods after insertion may be abnormal, in

the form of greater volume of flow during menstrual periods or prolonged
duration or both. The woman should be told beforehand that this is likely to
occur. Occasionally, the menstrual abnormality may last indefinitely, but
seldom becomes frankly haemorrhagic. If the bleeding is of any severity, the
device will probably have to be removed (Treiman et al., 1995).
No difference was identified in rates of removal for bleeding alone

or bleeding with pain between GyneFix and T-safe Cu380A (O’Brien &
Marfleet, 2003).
With Cu IUD blood flow increase on average by 20-50% bleeding

may be in the form of menorrhagia or menotaxis (Family Planning
Methods, 1996).
The most serious effect of increased menstrual bleeding is the

increased danger of anaemia (Pollack et al., 2006).
Various forms of treatment have been tried for the bleeding, but
none has proved entirely satisfactory. These include: ergotrate, ascorbic
acid, calcium, vitamins (especially vitamin K) and ferrous sulfate as well as
progesterone in the second half of the cycle (Treiman et al., 1995).
27
lactation
NSAIDs (Non Steroidal Anti Inflammatory Drugs e.g. mefenamic

acid) can be used to treat spotting, light bleeding and heavy or prolonged
menstruation. Antifibrinolytics (tranexamic acid) may be used for heavy or
prolonged menstruation (FFPRHC, 2004).
(2) Cramping and pain:
Some IUD users may experience a cramp like pain usually

manifested as discomfort and lower back pain caused by uterine contractions
in an attempt to expel the foreign body “IUD”. Prostaglandin synthetase
inhibitors such as naproxen, talfenamic acid and malfenamic alleviate that
pain and decrease blood loss (Population Reports, 1995).
Pain, usually in the form of uterine cramps, and occasionally as

low backache, may occur soon after insertion, although the only complaint
may be of some discomfort. Intermittent pain or discomfort is rarely present
for more than the first few weeks or months and is not as common as
abnormal bleeding. Women should be warned that some discomfort or mild
pain can be expected. Women vary greatly in their reaction to pain;
psychological and cultural factors often affect this reaction (Brueggemann,
1997).
Severe uterine cramps or syncope during the fitting of IUDs do

occasionally occur, but are rare and are usually found in nulliparous or in
women who have not had a child for some years. The appearance of uterine
cramps and irregular bleeding after months of freedom from any discomfort
should never be ignored; these symptoms may mean that the IUD is about to
be expelled from the uterus (Brueggemann, 1997).
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lactation
(3) IUD Expulsion:
The symptoms of IUD expulsion may include unusual vaginal

discharge, cramping or pain, inter-menstrual spotting, post coital spotting,
dyspareunia (male or female) lengthening of the IUD string, ability to feel
the hard IUD at the cervical os or in the vagina or passage of the IUD itself
from the vagina. IUD expulsion may cause penile pain or irritation (Hatcher
et al., 1998).
Expulsion is more common in the first year with the smaller

devices, in young women of low parity, and in postpartum insertion. If
expulsion is unnoticed, pregnancy may follow. At follow-up, if no threads
are present, three findings may have happened:
(1) The device may have been expelled (check for pregnancy).
(2) The device may have rotated inside the uterus, pulling the threads up
with this movement. It would then have to be removed and a new IUD
inserted.
(3) The woman may be pregnant and the threads will have been pulled up
into the enlarged uterus (Varney, 2004).
(4) Pregnancy with IUD still in place:
Pregnancy is one of the important complications that can occur

with an IUD in place. If a pregnancy does occur, it is best that the IUD be
removed. Tell the patient that she has about a 25% chance of having
29
lactation
spontaneous abortion and inform her to return should bleeding, cramping, or

signs of the infection occur (Treiman et al., 1995).
No case of malformation of available infant has been attributed to

an IUD remaining in the uterus during pregnancy. The device remains
outside the amniotic sac and is usually delivered with the membranes or
placenta (Treiman et al., 1995).
(5) Perforation of the uterus or translocation of the device:
The symptoms of uterine perforation may include pain at the time

of insertion, gradual disappearance of the IUD string over several weeks to
several months, bleeding after the insertion, and pregnancy. Immediate post
partum insertion of the loop is associated with a lesser risk of perforation
than insertion during the four to six weeks after delivery (Klienman, 1991).
Perforation is commonest at insertion, but may also occur during

attempted removal, especially of a tailless device. The incidence of
perforation probably varies considerably with the skill and experience of the
inserter. It has been conclusively proved that partial penetration of the
uterine wall at the time of insertion does not always precede perforation or
translocation. Most perforations are entirely asymptomatic and are
discovered at routine examination or at delivery (Klienman, 1991).
Perforation is more likely to occur if insertion is difficult. When

insertion presents real difficulty, it is advisable to give up the attempt. It is
often possible to insert the device more easily at the time of menstruation,
when there is less cervical resistance (Brueggemann, 1997).
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lactation
Uterine perforation occurs in less than 1 in 1000 insertions

(Harrison et al., 2003).
(6) Infertility:
A case-control study found that previous IUD use in nulliparous

women did not increase the risk of tubal occlusion and infertility, whereas
infection with C. trachomatis did (Hubacher et al., 2001). This was also
shown in a more recent multicentre prospective study (Sivin, 1992).
The balance of evidence suggests that the use of an IUD does not
affect return to fertility (Hubacher et al., 2001).
(7) Pelvic inflammatory disease (PID):
PID, the most serious complication related to IUD use, usually

occurs as a result of sexually transmitted infection such as Chlamydia or
gonorrhea. Much of this increased risk is probably confined to the first few
months after IUD insertion (Fathalla et al., 1990).
Indeed, IUDs are considered to cause PID by pushing vaginal and

cervical bacteria into the uterus along the tail of the device. However,
organisms cultured from the vagina of IUD users may or may not represent
microbes present in the uterus (Ferraz do Lago et al., 2003).
• Factors influencing the risk of infection:
1- Insertion:
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lactation
A woman is most likely to develop PID just after insertion of IUD.

Risk of developing PID was 3-6 times greater during 20 days after insertion
than any other later time (Farley et al., 1992).
We can minimize the risk of infection just after IUD insertion by

following infection prevention procedures during IUD insertion. A recent
cervical infection should be treated before IUD insertion (Anderson et al.,
1994).
2- Prophylactic antibiotic:
Interest has grown in the use of prophylactic antibiotics at the time

of insertion to decrease the risk of infection. Several studies where
undertaken, and although one study indicated a slight decrease in the risk of
PID with the use of prophylactic antibiotics, similar trials failed to show any
difference (Sinei et al., 1990 - Ladipo et al., 1991).
WHO does not recommend prophylactic antibiotics routinely for

IUD insertion. WHO recommends that prophylaxis may be considered in
settings of high STD prevalence and limited testing (WHO, 2002).
3- Type of IUD:
A WHO clinical trial data show no difference in infection rates

among unmedicated copper and hormonal IUDs but in developing countries
there is a greater risk of infection for women using unmedicated IUD than
Cu IUD (Buchan et al., 1990). There is a lower risk of tubal block with Cu
IUD than with unmedicated IUDs (Daling et al., 1992).
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lactation
4- Age:
As in other women, PID in IUD users occurs more often among

women under age 25. In international clinical trials sponsored by WHO, for
example, younger women suffered from PID at 2.5 times the rate of older
women. This may be at least in part because these younger women are less
likely to be married or to have mutually faithful sexual relationships
(Population Reports, 1995).
5- Duration of IUD use:
In most studies the chances of ever developing PID remain

unchanged or even decreased with duration of IUD (Sivin, 1992). Long
period of using Cu IUDs causes growth of Trichomonas vaginalis on the
genital mucosa therefore special attention must be given to women who have
had prolonged Cu IUDs for the possible presence of Trichomonas vaginalis
(Nasir et al., 2005).
Danger Signs: Early IUD danger signs:
- Period late (pregnancy) abnormal spotting or bleeding.
- Abdominal pain, pain with intercourse.
- Infection exposure (such as Gonorrhea), abnormal discharge.
- Not feeling well, fever, chills.
- String missing, shorter, longer (Hatcher et al., 1998).
33
lactation
The Future of IUD:
Worldwide, there are several IUD designs new to the market or

under development. The goals of these design modifications are to facilitate
easier insertion and removal, decrease the number of expulsions, and reduce
the pain or bleeding associated with some devices that can lead to
discontinuation. Some of the new devices are smaller, some are frameless,
and some combine copper and hormone components. None of the new
devices is currently available in the USA (Wildemeersch et al., 2003)
There is a great deal of clinical experience worldwide with the

frameless GyneFix® device, which consists of copper sleeves clamped onto
a string-like suture material (Wildemeersch et al., 2003). The device is
anchored via a knot that is pierced about one centimeter into the
myometrium. It has a smaller total surface area than standard IUDs, which is
believed to minimize menstrual bleeding. The device is associated with few
expulsions and high rates of continuation due to a low incidence of bleeding
or pain (Cao et al., 2004).
In addition to new devices, the use of IUD may shift in the future to
include a wider range of users. Greater numbers of nulliparous women,
interested in reversible, long-term, highly effective contraception may
choose the device, especially if overly strict selection criteria are revised.
IUD also may be used increasingly in the future for non-contraceptive
purposes, such as treatment of menorrhagia and provision of endometrial
protection during estrogen replacement therapy (Grimes et al., 2004).
34
lactation
(C) Progestogen-only contraceptives
Non-hormonal methods remain the first choice category of

contraceptive methods for breastfeeding women, since there is no possibility
that they will interfere with lactation (Kennedy et al., 1997).
Progestin-only methods comprise a viable and often desirable next

choice category, although the timing of their commencement must be
determined with care in order to support lactation (Kennedy et al., 1997).
Effect on infant growth:
Growth, development and health of infants whose mothers used

progestogen-only contraceptives during lactation were examined in a
prospective, non-randomized study carried out in seven centers in five
countries (Egypt, Thailand, Kenya, Chile and Hungary). Breastfeeding
women requesting effective contraception were admitted to the study at six
weeks postpartum. Infants of acceptors of progestogen-only methods and
non-hormonal methods (IUD, barrier methods or sterilization) formed the
study groups. The follow-up was at monthly intervals until the end of the
first postpartum year. Participating in the study were 2466 mother-infant
pairs. There were very few statistically significant differences in these rates
of change between groups within centers. Since a large number of statistical
comparisons were made, and there was no consistency either across centers,
over time, or in the direction of the differences, we conclude that in this
study, the progestogen-only contraceptives used during lactation did not
adversely affect infant growth. (WHO, 1994).
35
lactation
Premature introduction of progestin-only contraceptive

methods during lactation:
Experts on contraceptive technology concur that progestin-only

methods can be used safely during lactation. However, very few studies exist
of the effects on lactation of the introduction of progestin-only methods prior
to the sixth postpartum week. Since progesterone withdrawal is the likely
stimulus that initiates lactogenesis, it appears necessary for natural
progesterone levels to decline to baseline before a progestin-only
contraceptive is initiated. There-fore, the use of such contraceptive methods
should be delayed for at least 3 days after the birth (Kennedy et al., 1997).
1) Progestin –Only Pills (POPs) "The Minipill"
POPs are taken every day with no pill free interval. The
effectiveness of POPs is greater when the normal bleeding pattern is most
disturbed. If ovulation is not suppressed, the POPs have no effect on the
cyclicity of bleeding, and menstrual bleeding occurs as it had before the
woman started POPs. POPs are generally less effective than combined oral
contraceptives (COCs) (Biswas et al., 2008).
Ideally for women who desire a form of contraception in addition

to lactation-induced amenorrhea, progestin-only methods should be started
at six weeks postpartum if the woman is fully breastfeeding. Since
contraception protection is provided by lactation amenorrhea, the six week
delay will decrease infant exposure to exogenous hormones and decrease the
incidence of irregular postpartum bleeding. POPs do not appear to affect
36
lactation
milk volume, composition, or to cause deleterious effects in the infant

(Kelsey, 1996).
It is particularly important that POPs not be taken even a few hours

late, because of the loss of effectiveness. The sperm penetration of cervical
mucus increases if the time interval between POPs is more than 24 hours
(Townsend, 1990).
How POPs Work?
POPs have very low doses of progestin, lower than combined pills.
POPs prevent pregnancy in two main ways:
• They prevent ovulation in about half the cycles.
• They cause a thickening of the cervical mucus, which prevents sperm

from reaching the egg (FHI, 2009).
POPs also produce changes in the endometrium so that it becomes

less receptive to implantation in the unlikely case that ovulation occurs, and
POPs slow the movement of the egg through the fallopian tube. These
multiple mechanisms of action, along with the low doses of progestin
required, create most of the advantages, and the few disadvantages, of POPs
(FHI, 2009).
Advantages of POPs:
POPs are a good alternative. They have no adverse effects on

lactation. Most research has found either that they have positive effects—
37
lactation
increasing milk quantity or improving its nutritional quality—or that they

have no effect. Women who choose POPs can use them and continue to
breastfeed until lactation naturally stops (Population Reports, 2000).
Because women take the same type of pill every single day (same
color and hormone content), some women may find it easier to remember
(Hatcher et al., 1998).
Non-contraceptive health benefits:
Women taking POPs may note several beneficial effects during

their menstrual cycle such as decrease menstrual cramps or pain, less heavy
bleeding, a shorter period, decreased premenstrual syndrome symptoms and
decreased breast tenderness. In theory, the thick, less penetrable cervical
mucus in women on POPs should decrease the risk of PID. The POPs should
also make women less likely to develop endometrial cancer (Hatcher et al.,
2004).
Disadvantages:
Users experience an increased risk of functional ovarian cysts and

ectopic pregnancy. Moreover, there is a greater risk of pregnancy in women
who menstrual cycles are ovulatory and whose cycles are least disturbed
POPs have lower effectiveness, more breakthroughs bleeding, and

fewer non-contraceptive benefits than produced by COCs (Biswas et al.,
2008).
38
lactation
Selecting the POPs:
- Indications for use:
POPs are particularly desirable for:
• Women who have developed severe headaches or hypertension on COCs.
• Lactating women.
• Women with hypertension or vascular headache prior to initiating use of

hormonal contraceptive.
• Women who want to use an oral contraceptive but have contraindications

to COCs (Brueggemann, 1997).
- Contraindications to use:
The POPs carry the same absolute contraindication as COCs. There

are few relative contraindications to this method; a history of functional
ovarian cysts or ectopic pregnancy, or an inability to take the POPs
consistently and correctly. Because of the irregular bleeding patterns
associated with this method, unexplained abnormal vaginal bleeding during
the past three months is an important contraindication to the use of POPs
(Ladipo & Akinso, 2005).
Danger Signs:
■ Abdominal pain: may be due to an ovarian cyst or an ectopic pregnancy.

(Do not stop pills but contact us right away).
39
lactation
■ Pill taken late: even if only 3 hours late use a backup contraceptive for the
next two days. Be careful to take minipills on time (Hatcher et al., 1998).
Effect of POPs on pituitary–ovarian axis activity during

lactation:
We have monitored effects of POPs on ovarian activity during

breastfeeding. Twenty-one women, using barrier methods (BM) of
contraception and 9 women on POP were enrolled 6 weeks postpartum (PP)
and followed-up to 18 weeks PP. There was little change in plasma follicle-
stimulating hormone and luteinizing hormone, and no differences between
BM and POPs. POPs did not affect plasma estradiol. There was no
difference between BM and POPs in plasma inhibin B concentrations. The
size of follicles was similar in both groups in all time points. There was an
increase in the endometrial thickness from 6 weeks PP to 18 weeks PP in
BM, but no differences within the POPs group or between the treatment
groups. POPs does not suppress gonadotropins nor affect growth of ovarian
follicles during breastfeeding. Thus, the contraceptive effect of POPs is
likely mediated through local actions at the endometrium and cervix in a
manner similar to that in menstruating women (Perheentupa et al., 2003).
2) Norplant Implants
When a woman decides to have Norplant implants inserted in a

minor surgical procedure, under local anesthesia - a single decision provides
her with 5 years of birth control. At the same time, the woman can be
assured that she can have the method reversed at any time, by having the
40
lactation
capsules removed. The contraceptive steroid Levonorgestrel slowly diffuses

through 6 slender, flexible capsules. When the capsules are removed, the
contraceptive effect wears off quickly. Norplant implants are usually placed
under the skin on the inside of woman’s upper arm in a fan-shaped
configuration using a simple trocar. It is recommended that Norplant
implants be replaced after 5 years (Ladipo & Akinso, 2005).
Effectiveness:
Norplant’s failure is rare. The rate of accidental pregnancy in the

first year of use is 0.2%. Because the failure rate increases to an
unacceptable level in the sixth year, the capsules should be removed at the
end of the fifth year. If the woman wishes to continue with Norplant, another
set of capsules can be inserted when the first is removed (Ladipo & Akinso,
2005).
Advantages:
Because Norplant contains no estrogen, it therefore produces no

estrogen-related side effects. The low and constant release of progestin
avoids the hormonal surge of an oral contraceptive and the high initial dose
of injectables (Chasin & Langer, 1990).
Norplant has higher continuation rates than do other hormonal

contraceptives. The percentage of women continuing to use Norplant at 1
year is 85%. The continuation rate is about 15% less for women using pills
or DMPA (Hatcher & Kowal, 2000).
41
lactation
Norplant (and to a lesser extent, DMPA) is an excellent

contraceptive option for women who have difficulty remembering to take
pills or in using methods requiring interruption of intercourse (Hatcher &
Kowal, 2000).
In addition to the excellent protection against pregnancy, the

potential non-contraception benefits of Norplant implants may include
scanty menses or no menses, decreased anemia, decreased menstrual cramps
and pain and suppressed ovulatory pain. Users may have a possible
reduction in risk of endometrial cancer, as do users of COCs (Population
Reports, 1996).
Disadvantages:
Users may experience alternation in bleeding patterns, including

prolonged menstrual bleeding, spotting between periods, very scanty menses
or no menses at all (Ladipo & Akinso, 2005).
Insertion and removal must be performed by clinical practitioners,

thus creating more provider responsibility and less personal control by users.
The practitioners will need special training in implant insertion and
removal, counseling and aseptic technique (Sivin et al., 2002).
Indication for use:
Norplant is particularly suited for women who
42
lactation
• Seek continuous contraception or want long term birth spacing.
• Desire a method not related to intercourse.
• Desire a method that does not have to be remembered every day.
• Have the number of children they want, but do not want to be sterilized at
this time.
• Want to be sterilized but do not meet the criteria required locally regarding
age and number of children.
• Can not be sterilized because of inadequate resources, such as medical

personnel or operating room facilities.
• Are late in their reproductive years and whose clinicians would rather not
use an estrogen containing contraceptive.
• Have had side effects from COCs (Hatcher et al., 2004).
Contraindications to use:
There are relatively few contraindications to Norplant use:
■ A history of blood clots in the legs (thrombophlebitis), lungs (pulmonary

embolism), or eyes.
■ Acute liver disease and/or Jaundice.
■ Unexplained vaginal bleeding (until a diagnosis is reached by the doctor).
43
lactation
■ A history of heart attacks, chest pain due to diagnosed heart disease, or

stroke (coronary artery or cerebrovascular disease) (Hatcher et al., 2004).
Norplant should not be used by a woman who is pregnant:
If a woman becomes pregnant and plans to continue her pregnancy,

the implants should be removed. It is not a good policy to expose the fetus
to additional hormones, although the amount of the dosage from the
implants is small (Hatcher et al., 1998).
Use during lactation:
Steroids are not considered the contraceptives of the first choice

for breast feeding women. Studies have shown no significant effects on the
growth or health of infants whose mothers used Norplant beginning 6 weeks
after childbirth. Thus, if a lactating woman wants to use Norplant, the
capsules should be inserted no earlier than 6 weeks of post-partum
(Townsend, 1990).
Other factors to be considered before prescribing Norplant, the

health care provider should ask a woman if she has any of these conditions:
● Breast nodules, fibrocystic disease of the breast, an abnormal breast x-ray

or mammogram.
● Diabetes, elevated cholesterol or triglyceride, high blood pressure.
● Epilepsy, mental depression, gall bladder, heart or kidney disease.
● Migraine or other headaches (Hatcher et al., 1998).
44
lactation
A woman with any of these conditions should be checked by her

health care provider if she chooses Norplant. The provider should also ask if
the woman smokes or takes any medications. Because smoking increases the
risk of heart attacks and strokes, Norplant users are advised not to smoke
Side effects and warnings:
1) Menstrual cycle changes.
2) Insertion and removal problems:
When Norplant is not inserted properly, removals may be more

difficult. Infection at the implant site has been uncommon and is usually
associated with inadequate asepsis during implant placement. Difficult
removals may also occur when person attempting to remove implants has
not had experience with the procedure (Varney et al., 2004).
3) Ectopic pregnancy:
The rate of ectopic pregnancy is lower than the rate of ectopic

pregnancy in women using no contraception. Since the absolute risk of
ectopic pregnancy may increase as the risk of pregnancy increases, it is
important that the implant be removed after 5 years (Li et al., 1992).
The use of implant, uniplant, during lactation:
Uniplant is a single contraceptive implant intended for one year

use. It contains the progestogen nomegestrol acetate. The clinical
45
lactation
performance and the effect of its use during the first postpartum year on
breastfeeding performance and growth and health of the infants were studied
and compared to the findings in a parallel group who used an IUD in a
prospective, non-randomized study. This was carried out in Assiut, Egypt.
Two-hundred-forty fully breastfeeding mothers asking for initiation of
contraception early postpartum were assigned according to their choices into
either Uniplant (120 women) or IUD (CuT 380A) (120 women). The mother
and infant pairs were followed up at monthly intervals during the first three
months and at two-month intervals thereafter up until the first birthday of the
baby. No pregnancy occurred in the two groups. Amenorrhea was
significantly more prolonged in the Uniplant group than in the IUD group.
There were no significant differences in net continuation rates between the
two groups. There were no significant differences between the two groups in
the number of breastfeeding episodes, time of weaning, and the cumulative
rates of full and partial breastfeeding. There were no significant differences
between the two groups in infant weight, weight gain per day, or in infant
linear growth. There were no significant differences in the incidence of
important health problems affecting the infants of the two groups. However,
there were seven infant deaths; six of them were in the Uniplant group.
Uniplant implants can be offered as a new contraceptive option suitable for
nursing mothers (Abdel-Aleem et al., 1996).
Influence of implants, initiated early postpartum upon

lactation and infant growth:
NORPLANTR implants were inserted between days 30 and 42

postpartum in 50 lactating women. Two control groups of breastfeeding
46
lactation
mothers, 50 each, were studied in parallel: the first used an IUD (Cu T380A)
and the second used either barrier or no contraception. There was no
difference in lactational performance among the three groups. The
increments in infant weight and height in the three groups were within the
normal range for Egyptian infants. However, the rates of weight and height
gain in the early postpartum months were slightly, but significantly, lower in
the NORPLANTR group than in the two control groups. However, by the
sixth postpartum month, there were no significant group differences in these
growth parameters (Population Reports, 1996).
Effect of early postpartum use of the contraceptive implants,

on the serum levels of immunoglobulins of the mothers and
their breastfed infants:
Ten breastfeeding women had the contraceptive implants

NORPLANTR inserted between days 30 and 39 postpartum. The
immunoglobulins IgG, IgM and IgA were measured in the serum of the
mothers and the infants before insertion and five months later. A control
group of breastfeeding mothers who did not use any contraception or used
local barrier methods were similarly studied. Although there were changes in
the immunoglobulin levels with time in both mothers and infants, there were
no group differences; this indicates that the use of NORPLANTR does not
influence these factors of humoral immunity (Sivin et al., 2002).
47
lactation
Use of a single implant of Elcometrine (ST-1435), as a long

acting contraceptive for postpartum nursing women:
Because of its unique features, the contraceptive effectiveness and

tolerance during breast-feeding of 16-methylene-17α-acetoxy-19-nor-4-
pregnene-3, 20-dione (Elcometrine), delivered within a single subdermal
capsule of medical grade polydimethylsiloxane, was investigated. Unlike
other progestational steroids, Elcometrine has no affinity for androgen and
estrogen receptors and is inactive by the oral route. There were no
significant differences in growth and development measurements among the
infants in the Elcometrine and control groups. The percentage of infants
continuing to breast-feed at 3 and 6 months was significantly higher in the
Elcometrine group. There were no significant differences between the
concentration of Elcometrine in the mother’s blood and milk (Coutinho et
al., 1999).
-Conclusion:
A single Elcometrine capsule placed subcutaneously at 6-monthly

intervals appears to be an effective method of contraception for lactating
women and results in blood concentrations of nursing infants at or near
undetectable levels (Coutinho et al., 1999).
Danger signs:
■ Severe lower abdominal pain (ectopic pregnancy is rare but can occur).
■ Heavy vaginal bleeding.
48
lactation
■ Arm pain.
■ Pus or bleeding at the insertion site (these may be signs of infection).
■ Expulsion of an implant.
■ Delayed menstrual periods after a long interval of regular periods.
■ Migraine, headaches, repeated very painful headaches, or blurred vision

• Biodegradable implants: Implants which deliver progestins from

a carrier that gradually dissolve in body tissue. Once the carrier has started
to dissolve, it can not be removed (Hatcher et al., 1998).
3) Injectable Progestins "Depo-provera"
The use of injectable progestins has been effective and popular in a

number of countries. The most commonly used injectable progestins are
medroxy progesterone acetate (Depo-provera or DMPA) and norethindrone
enanthate (NET). They exert their actions by mechanisms similar to those of
other progestin-only contraceptives. Both injectables have reported failure
rates typically less than 1 failure per 100 women per year (Hatcher &
Kowal, 2000).
Advantages:
Depo-provera does not have some of the serious complications

associated with estrogen-containing pills. It is highly effective, long acting.
(Provided at 3 months intervals 6 months in some research settings), and
49
lactation
continues effective protection for several weeks even if the user is late in
receiving the next injection. Because it is a long acting injectable, DMPA is
not related to sexual intercourse and offers privacy to the user since the
woman has no need to keep contraceptive supplies at home. Although some
women may find the prolonged amenorrhea a disadvantage, others find it
desirable (Hatcher et al., 2004).
By stopping menstrual periods or decreasing menstrual flow,

DMPA may decrease the menstrual cramps and pain blood flow,
premenstrual symptoms and ovulatory pain experienced by some Women.
DMPA has been used in the treatment of heavy menstrual periods
accompanied by anemia, dysmenorrhea and endometriosis. DMPA may also
prove to benefit menopausal women at risk for osteoporosis. Some evidence
suggests that DMPA does not suppress lactation and may even increase the
length of time a woman is able to breast feed (Hatcher et al., 2004).
Safety:
Long-term users of DMPA may have lower bone density than

nonusers, probably reflecting reduced estrogen levels; however, this effect
has not been associated with increased fractures (Cundy et al., 1991).
Other investigators have not detected bone loss during 3 years or

more of DMPA use (Taneepanichskul et al., 1997).
A small study comparing DMPA to implant or OC users found that

DMPA blocked the usual rapid increase in bone density normally seen in
50
lactation
adolescents (Cromer et al., 1996). This may suggest that DMPA may be less
desirable for young adolescents. The effect of DMPA on plasma lipids has
been inconsistent; in general, DMPA users appear to have reduced total
cholesterol and triglycerides, slight reduction in HDL cholesterol, and no
change or slight increase in LDL cholesterol, all of which are consistent with
a reduction in circulating estrogen levels. In some studies, the decrease in
HDL and increase in LDL are statistically significant, although the values
remain within normal ranges (Fahmy et al. 1991).
The use of DMPA has not been associated with myocardial

infarction. Glucose tolerance tests disclose a small elevation of glucose in
DMPA users. There is no change in hemostatic parameters, with the
exception that antithrombin III levels are sometimes found to be reduced
with chronic therapy (Fahmy et al. 1991).
DMPA has not been linked to thrombotic episodes in women of

reproductive age. However, thrombotic episodes have occurred in elderly
women with advanced cancer who were treated with a variety of agents,
including DMPA and tamoxifen (Ishizaki et al., 1992).
Such patients are at high risk for thrombosis regardless of the use
of DMPA. Women taking DMPA appear to experience a weight gain of 2 to
3 pounds more than nonusers over several years. Its use has not been
associated with teratogenesis. It is safe for use by lactating women and, as
with other progestin-only hormonal methods, appears to increase milk
production. DMPA has not been associated with affective disorders or mood
changes, although the data are limited (Westoff, 1996).
51
lactation
Selecting DMPA:
- Indications for use: Depo-provera is indicated for a woman who
■ Is breast feeding her baby.
■ Wants no more children but does not want to be or can not be sterilized.
■ Is in her reproductive years when the risks of COCs are greatest.
■ Wants a safe, effective method for a short period of time before she is
sterilized for example, if she is a post-partum patient who is unable to
schedule tubal ligation for several months.
■ Is living under conditions where personal hygiene is difficult.
■ Has sickle cell disease and is not or good candidate for combined pills.
■ Has developed estrogen-related complications while taking COCs or is at

risk for developing cardiovascular complications. The characteristics of such
patients might include high blood pressure, headaches, leg pain, heavy
smoking, hyperlipemia, over 40 years of age (Brueggemann, 1997).
- Contraindications to use: Like Norplant implant.
Side effects and complications:
Excessive endometrial bleeding and amenorrhea are the most

frequent reasons for discontinuing DMPA. Women using DMPA may have
break through bleeding that can be managed with 1 or 2 cycles of an OC.
However, the provision of COCs or any other exogenous estrogen is usually
52
lactation
unnecessary. Occasionally, women using DMPA bleed numerous days each

month, and should be checked for anemia. A woman whose hematocrite
drops 5 points or more should discontinue DMPA or receive iron
supplement. Amenorrhea is to be expected after 9 to 12 months of using
DMPA. Many women consider amenorrhea a desirable effect of DMPA.
Others clearly do not (Brueggemann, 1997).
NET produces substantially less amenorrhea than does DMPA.

Many women experience post DMPA infertility lasting 6 to 12 months.
Extensive worldwide studies of DMPA indicate that the delay in the return
to fertility does not lead to long term infertility (Brueggemann, 1997).
DMPA users occasionally report decreased libido, depression,

headaches, dizziness, weight gain and allergic reactions (Hatcher et al.,
1998).
DMPA apparently has no effect on blood pressure. There is no

evidence of thromboembolic phenomena or other circulating disease of
thromboembolic phenomena or other circulatory disease occurring with
estrogen-containing oral contraceptives (Hatcher et al., 1998).
Danger signs:
Weight gain, headaches, heavy bleeding, depression and frequent

urination (Hatcher et al., 1998).
53
lactation
(D) Local Methods
a) The condom:
Condoms are safe and effective methods of birth control. Except

for coitus interrupts, condoms are the only non-permanent method of birth
control for men, given the ability of condoms to prevent the transmission of
AIDs and other STDs. The benefits of condom extend far beyond
contraception (Fathalla et al., 1990).
Effectiveness:
First year failure rates among typical users average about 12%.
Foam sometimes recommended for use in conjunction with condoms in an
effort to increase effectiveness (Berek, 2002).
Prevention of AIDs and STDs:
Condoms can clearly play a major role in the prevention of STDs,

including AIDs. Use of spermicidal condoms is the best approach to the
prevention of STDs; herpes simplex, AIDs, human Papilloma virus (HPV),
gonorrhea, trichomonas, hepatitis B, syphilis and chlamydia. Women at high
risk for these STDs infections should use condoms consistently during
pregnancy to protect the baby as well as their husband (Pope et al., 1992).
Non-contraceptive benefits:
■ Condoms are relatively inexpensive and may even be obtained for free.
54
lactation
■ Use of condoms encourages male participation in contraception and

protection from infection.
■ Condoms are accessible, their use does not require an examination

prescription or fitting.
■ Some women and men do not wish to have the penis in direct contact with
the vagina. The condom is an effective barrier that may make intercourse
more pleasurable if this concern exits.
■ Men who have difficulty maintaining an erection may find that the rim of
the condom may have a slight tourniquet effect, helping to maintain an
erection.
■ Lubricated condoms can reduce mechanical friction and irritation of the

penis or vagina.
■ By diminishing STDs infections, condoms may diminish the likelihood of

infertility or cervical cancer in some women.
■ Condom use may prevent the development or cause the regression of

cervical intraepithelial neoplasia (Hatcher et al., 2004).
Contraindications:
There are few contraindications to condom use:
• Men or women who are allergic to rubber in condoms.
• The male husband will not accept the respectability for birth control.
55
lactation
• Natural skin condoms are probably contraindicated where there is a risk of

infection since they allow passage of very small viruses such as the HIV
Side effects and complications:
The major complaint of condom users is that the condom reduces

glans sensitivity. In order to provide a perception of increased sensitivity
natural memb, textured, ribbed, ultra-thin or lubricated condoms may be
used. Greater care has to be taken with thin condoms because they break and
tear more easily (Finger, 1990).
b) Sponge:
Natural sea sponges, often soaked with a spermicide prior to

insertion into the vagina. It is a small pillow-shaped polyurethane sponge
that contains 1 gram of nonoxyol-9 spermicide. The today sponge has a
concave dimple on one side that is intended to fit over the cervix and
decrease the chance of dislodgment during intercourse. The other side of
the sponge incorporates a woven polyester loop to facilitate removal
The sponge is available in one size. The sponge is moistened with

tap water prior to use and inserted deep into the vagina. Once in place, the
sponge provides continuous protection for up to 24 hours. After use the
sponge is discarded (Hatcher et al., 2004).
56
lactation
c) Diaphragm:
Diaphragm is a dome-shaped rubber cup with flexible rim. It is

inserted into the vagina before intercourse so that the posterior rim rests in
the posterior fornix and the anterior rim fits snugly behind the pubic bone,
with the dome covering the cervix. Spermicidal cream or jelly placed in the
dome before insertion is hold in place near the surface of the cervix
Diaphragms are available in a range of sizes and in four styles that

differ in the inner construction of the circular rim: - Arching spring - coil
spring - wide seal rim & flat spring (Varney et al., 2004).
Fig. 3: Types of diaphragms (Hatcher & Kowal, 2000).
57
lactation
d) Cervical Cap:
The cervical cap is a cup-shaped device that fits over the cervix and
is held in place, at least partially, by suction between its firm, flexible rim
and the surface of the cervix or upper vaginal wall. Caps currently being
used are made of soft rubber. They are not suitable for prolonged wear
because a strong odor appears after 36 to 48 hours of wear and because
there is a theoretical risk of toxic shock syndrome (Hatcher et al., 1998).
Manufacturer’s recommendation that accompany the cap suggest

using spermicide inside the cap (to fill one-third of the cap) and specify time
rules for insertion and removal of the cap that are similar to instructions for
using a diaphragm. There are three cervical cap styles currently available
each in a range of sizes named by the cap rim diameter in millimeters.
Dumas cap, vimule cap, prentif cavity rim cervical cap (Hatcher et al.,
1998).
Fig. 4: Two cervical caps (Hatcher & Kowal, 2000).
58
lactation
e) Silastic vaginal rings:
1- The vaginal ring delivers combined progestogen and estrogen

through a silastic wall. The device can be left in place for 21 days out of 28,
and such delivery would virtually eliminate the low risk of hepatocellular
carcinoma among COC users (Potts & Smith, 1991).
2- Silastic vaginal ring release levonorgestrel (WHO, 1993).
3- Silastic vaginal ring release natural progesterone to be used

during lactation (Landgren et al., 1992).
f) Female condom:
It is a barrier method that is female-based not dependent on male

erection and intercourse, and is effective as prophylaxis against STDs,
including AIDS. It is a soft polyurethane sheath, 15 cm long, covers loosely
vagina & vulva and has outer ring (7 cm) covers external genitalia, base of
penis during coitus and inner ring (6.5 cm) which is used as introducer and
anchoring the condom in the vagina. The device can be inserted well before
intercourse, and must be used with a lubricant applied to the inside to
prevent penile irritation (Fathalla et al., 1990).
g) Spermicides:
Spermicides preparations consist of two components; a sperm-

killing chemical and a base or carrier. The carrier is responsible for
dispersing the chemical inside the vagina over the cervix, and holding it in
59
lactation
place so that no sperm can escape contact with the spermicidal ingredient.
For foaming product, the base also contributes a physical barrier to reduce
contact between semen and the cervix. The active spermicidal ingredient in
many modern products is nonoxynol-9, a potent surfactant that kills sperm
cells by destroying the cell membrane (Brueggemann, 1997).
Octoxynol, menfegol, and benzalkonium chloride are also

surfactant spermicides. Menfegol is the spermicide in the foaming vaginal
suppositories called Neosampoon. Spermicidal chemicals can be delivered
in cream or gel, foam, melting suppository, foaming suppository, foaming
tablet, or soluble film (Brueggemann, 1997).
Cream and gels can be used alone or in conjunction with a

diaphragm or cap. Foam is intended for use alone. Suppositories and tablets
require a waiting interval of at least 10-15 minutes after insertion for
dispersion to occur, and may possibly fail to melt or foam. Film packaged is
thin, 2-inch sheets is extremely discreet and portable, but proper placement
is tricky and an interval of 15 minutes is essential (Brueggemann, 1997).
Spermicides can be used in combination with condoms to provide

extremely effective contraceptive protection as well as protection against
STDs (Fathalla et al., 1990).
Spermicidal douche after intercourse is not a reliable contraceptive

approach because sperms enter the cervical canal within seconds after
ejaculation, if a woman chooses to douche following sexual intercourse; she
should wait 6 to 8 hours if a vaginal spermicide has been employed as
method of contraception (Varney et al., 2004).
60
lactation
■ Vaginal contraceptive activity of a chelated vanadocene: a rapid

and potent inhibitor of human sperm motility with potential as a new class of
contraceptive agent. Intravaginal use of Vanadocene dithiocarbamate
(VDDTC) via a gel micro emulsion has clinical potential as a safe
alternative to currently used detergent-type contraceptives (D'Cruz &
Uckun, 2005).
Effectiveness of local methods:
A woman who is at high risk for pregnancy, is in the peak

reproductive age range (20-35 years), and has intercourse frequently (four
times weekly), should not expect highly effective contraceptive protection
with any of these methods, unless she uses them perfectly. Even then, failure
rates are likely to be at least 3% to 5% during the first year (Hatcher et al.,
1998).
A woman whose risk of pregnancy is low because of intermittent

sexual exposure, age less than 16 years or over 35 years, and infrequent
intercourse, can reasonably accept a fairly low failure rate with continuous
use of a spermicide, diaphragm, or cap, and if she is nulliparous, with use of
sponges as well. Alternatively, concomitant use of condoms for one week
during each cycle, beginning 4 to 5 days before ovulation, may improve
efficacy with less inconvenience (Hatcher et al., 1998).
Advantages and Non-contraceptive benefits:
• Spermicides and / or vaginal barriers can be used consistently or at

midcycle to augment the efficacy of fertility awareness method.
61
lactation
• Spermicides and contraceptive sponge can be provided without the

necessity for any encounter with the medical system. Their use is simple and
can be mastered without written language (Varney et al., 2004).
• A woman can use a spermicide or a vaginal barrier method without the

necessity for husband involvement in the decision or in implementation
• Spermicides and vaginal BM can be kept available for immediate

protection whenever it is needed, no matter how long the interval between
uses (Varney et al., 2004).
• Spermicides and vaginal BM are a simple backup option when a woman is

waiting to begin the first back of birth control pills during the first month of
pill use, or when a woman forgets to take two or more pills or runs out of
pills (Brueggemann, 1997).
• Spermicides (and / or condoms or vaginal BM) can be used consistently or

at midcycle to augment the effectiveness of the IUD as an interim method
while waiting to have an IUD inserted, or as a backup method for a woman
who suspects that her IUD may be expelled (Brueggemann, 1997).
• Spermicides can be used to provide lubrication during intercourse.
• Sponge can be used to decrease vaginal discharge after intercourse.
• Spermicides can be used as an emergency measure in case of condoms

break (Brueggemann, 1997).
62
lactation
Contraindications:
Use of cervical cap is contraindicated for a woman who has an

abnormal Pap smear result, when cervical or uterine malignancy is known or
suspected, and when vaginal or cervical infection is present.
■ Allergy to spermicide or, for vaginal barriers, rubber, or latex, or

polyurethane.
■ Abnormalities in vaginal anatomy that interferes with appropriate

placement of spermicides or sponge, or interfere with satisfactory fit.
■ Inability to learn correct insertion technique.
■ History of toxic shock syndrome (for diaphragm, cap and sponge).
■ Repeated UTI (for diaphragm and cap.)
■ Lack of trained personnel to fit the device and/or lack of clinical time to
provide instruction and use (for diaphragm and cap).
■ Lack of facilities such as clean water and soap necessary in caring for the
device (For the diaphragm and cap).
■ Full term delivery within the past 6 weeks, recent spontaneous or induced
abortion, or vaginal bleeding from any cause, including normal menstrual
flow (for the cap and sponges) (Hatcher et al., 1998).
63
lactation
Side Effects:
1- Local skin irritation:
Caused by sensitivity or allergy is most common problem

associated with spermicide use and with use of diaphragm, cap and sponge.
In some cases, changing to an alternative spermicide product is helpful.
Husband discomfort may also occur due to mechanical contact with the rim
of the diaphragm or cap. An alternatives size or rim type may resolve the
problem (Brueggemann, 1997).
2- Foul odor and vaginal discharge:
Are likely to occur if a diaphragm, cap or sponge is left in the

vagina for more than a few days (Hatcher & Kowal, 2000).
3- Vaginal trauma:
Including abrasion and laceration may occur with use of cap or

diaphragm (Hatcher & Kowal, 2000).
4- Infection:
A significantly increased risk for urinary tract infection (UTI) has

been documented for diaphragm users. When recurring UTIs occur in
association with diaphragm use, it is reasonable to consider refitting the
patient with a smaller diaphragm size or alternative rim style. If UTI
problems persist the patient should choose an alternative method of birth
control (Black et al., 2004).
64
lactation
It is possible that prolonged exposure to spermicide or to a pool of

secretions in the cap could alter the cervical epithelial expression of the HPV
infection or even susceptibility to infection. A Pap smear before the cap is
provided is essential to identify patients who may have evidence of HPV
infection. A repeat Pap smear after 3 months of cap use is also essential
precaution. If the three months Pap is abnormal, cap use must be
discontinued (Hatcher et al., 1998).
5- Toxic shock syndrome (TSS):
TSS is a rare but serious disorder caused by toxin released by some

strains of staphylococcus aureus bacteria. The toxin causes sudden onset of
high fever, diarrhea, vomiting, malaise, inflamed eyes, and after a day or
two, diffuse sunburn-like rash. Cases of TSS have been reported in
association with use of contraceptive, sponges and the diaphragm. Patients
using these methods should be aware of TSS danger signs and instructions
for method use should be consistent with recommended TSS precaution
(Berek, 2002).
(E) Combined Oral Contraceptives (COCs)

"The Pill"
COCs should not be used in the first 6 weeks postpartum. COCs

are considered by many experts to be the method of LAST choice during any
state of lactation, especially in the first 6 weeks to 6 months. After 6 to 8
65
lactation
weeks postpartum, breastfeeding women desiring hormonal contraception

should be encouraged to use POPs, injectables or Norplant® implants
Even low dose (30 to 35 micrograms of estrogen) COCs decrease

breast milk production (WHO, 2004).
Indications:
(1) Sexually active young women.
(2) Couples using birth control for spacing.
(3) Nulliparous women.
(4) Sexually active adolescents.
(5) Non lactating post partum women.
(6) Immediate post abortion period.
(7) Need for short or long term reversible birth control.
(8) Need for post coital birth control.
(9) Acne.
(10) Heavy and painful menstrual periods.
(11) Recurrent ovarian cysts.
(12) Family history of ovarian cancer (Hatcher et al 2004).
66
lactation
Post partum and post abortion provision of pills:
In a woman who is not lactating, combined pills may be started

immediately following an abortion or 2-3 weeks following pregnancy. Low
dose COCs appear to have little effect on nutritional status of infant and the
hormones in COCs that appear in small amount in breast milk appear not to
affect breast fed babies (Townsend, 1990).
For women who are planning to gradually wean their infant, use of
COCs may provide an easier transition to bottle-feeding. COCs should be
used with caution by women who are not able to obtain supplemental milk.
A decrease in milk volume can lead to earlier discontinuation of the
hormonal contraceptive in an attempt to increase milk quantity.
Supplementation is often needed, and then the woman ovulates again,
possibly resulting in an unintended pregnancy (Kelsey, 1996).
Advantages:
1) Effectiveness:
The pill is the most effective reversible method of contraception.

The lowest reported first-year failure rate is 0.1%. For the more typical user
who may occasionally miss a pill, the first-year failure rate is about 3%.
Unplanned pregnancies can occur when women miss taking pills at the
beginning of a new cycle because this omission lengthens the pill free
interval. The pill free interval is also increased when woman fails to take
any of the last few active pills in the packet. To improve the effectiveness of
67
lactation
low dose combined pills, some clinicians routinely recommend that women
reduce the pill-free interval from 7 days to 4-5 days (Hatcher et al., 1998).
2) Safety:
Pills are extremely safe for young women. It is safer to use the pills
than to deliver a baby, unless a woman is over 35 years of age and smokes
more than 35 cigarettes/day (Grimes, 1992).
Non-Contraceptive Health Benefits:
1) Relief of cyclic problems:
The pill minimizes menstrual cramps, decreases the number of

days of bleeding and the amount of blood loss, increases menstrual period
regularity, decreases the incidence of functional ovarian cysts and decrease
mittelschmerz pain (pain at the time of ovulation). Also iron deficiency
anemia is decreased in pill users. Some women notice that their
premenstrual tension, anxiety, or depression is diminished while taking oral
contraceptives (Hatcher et al., 2004).
2) Protection against ovarian and endometrial cancer:
COCs use produces strong and lasting reduced risk for endometrial
and ovarian cancer. In addition, protection has been found for women with
known hereditary ovarian cancer. Any past use of COCs conferred a 50%
reduction in ovarian cancer risk when women with this history who took
COCs were compared with their sisters as controls. Protection increased
with increasing duration of use (Narod et al., 1998).
68
lactation
3) Protection against acute PID:
Chlamydial colonization of the cervix appears more likely in COC

users than in nonusers but, despite this, there is a 40% to 50% reduction in
risk for chlamydial PID (Berek, 2002).
4) Recurrent ovarian cysts & benign breast disease:
There is a significant reduction in the need for biopsies for benign

breast disease and surgery for ovarian cysts. All COCs offer some protection
from functional ovarian cysts, but multiphasic preparations offer less
protection than other forms of COCs (Berek, 2002).
5) Ectopic Pregnancy:
By stopping ovulation, pills prevent ectopic pregnancies, an

important cause of maternal mortality throughout the world (Hatcher et al.,
2004).
6) Excellent reversibility:
A pill user will not experience decreased fertility, although it may

take longer for her to become pregnant after taking pills than after using
other contraceptives (Hatcher et al., 1998).
Disadvantages:
■ No protection against HIV:
69
lactation
Condoms should be used in addition to pills, if protection against

HIV is desired in an intimate sexual relationship (Townsend, 1993).
■ Undesirable side effects:
• Missed periods or very scanty bleeding.
• Spotting or break through bleeding between periods.
• Nausea during the first cycle of pills or during the first few pills of each
new package.
• Breast fullness or tenderness.
• Mood changes including depression.
• Weight change.
• Chloasma and other skin changes (telangiectasia), neurodermatitis,

erythema multiform, erythema nodosum, eczema, photosensitivity and loss
of scalp hair (alopecia) (Hatcher et al., 2004).
■ Sex and the pill:
Some pill users experience a decreased sex drive; some women

also have a decrease in lubrication, making sexual intercourse less
comfortable (and occasionally painful). Other pill users enjoy sex more
because the fear of pregnancy is removed by pills (Hatcher & Kowal,
2000).
70
lactation
■ Breast feeding problems:
Pills appear to diminish both the volume and protein content of

breast milk in some lactating women. In addition, the hormones in birth
control pills are present in small amounts in the breast milk. Most clinicians
prefer that women avoid COCs during lactation. POPs are a better choice
than COCs for lactating women (Townsend, 1990).
■ Headache:
Some women develop severe, recurrent or persistent headache

while taking pills. Others note an increase in the severity of migraine
headaches. Pill-induced headaches are sometimes associated with blurred
vision, loss of vision, and nausea, vomiting or weakness in an extremity.
Severe headache may be an early warning of a stroke that needs to be
evaluated (Townsend, 1993).
■ Eye problems:
Visual problems such as blurred vision or loss of vision may

accompany headaches and transient ischemia. On rare occasions, pills may
cause inflammation of the optic nerve with loss of vision, double vision or
swelling or pain in one or both eyes. Women using COCs are at an increased
risk for retinal artery and retinal vein thrombosis (Hatcher et al., 2004).
Pill- related fluid retention may cause corneal edema, leading to an

increased like hood of discomfort or even corneal damage among contact
lens users, although modern soft contact lenses and low-dose COCs have
71
lactation
diminished this problem. There is no evidence that pills can cause or

aggravate glaucoma (Hatcher et al., 2004).
■ Circulatory disorders:
They are the most important complications attributable to oral

contraceptive use. Thrombophlebitis, pulmonary embolism, myocardial
infarction (heart attacks), thrombotic stroke, haemorrhagic stroke,
including subarachnoid haemorrhage, retinal vein thrombosis, mesenteric
vein thrombosis and pelvic vein thrombosis. The risk of these complications
is particularly elevated in women older than 35 years who smoke (Gerstman
et al., 1991).
Although healthy young non-smoker can take the pill with very
little risk of serious complications, other women do have an increased risk of
cardiovascular side effects:
(1) Women who smoke:
(2) Women who are over 35 years of age.
(3) Women who have other health problems such as hypertension, diabetes
or history of heart or vascular diseases.
(4) Women who have a family history of diabetes or a heart attack in a

person under the age of 50 years, particularly heart attack in a female
relative; (these women are at increased risk for cardiovascular disease
whether or not they use COCs) (Hatcher et al., 1998).
72
lactation
■ Hypertension:
Oral contraceptives have a dose-related effect on blood pressure

(BP). With the older high-dose pills, as many as 5% of patients could be
expected to have BP levels of higher than 140/90 mm Hg. The mechanism is
believed to be an estrogen-induced increase in renin substrate in susceptible
individuals. Current low-dose pills have minimal BP effects, but
surveillance of BP is still advised to detect the occasional idiosyncratic
response (Berek, 2002).
■ COCs and Neoplasia:
COCs reduce the risk for subsequent endometrial cancer and

ovarian cancer (Berek, 2002). A recent study found that as little as 1 year of
COC use was protective and continued use reduced risk by 7% per year.
Benefit persisted for 15 years after last use, with little diminution (Siskind et
al., 2000).
COCs have been implicated as a cause of benign adenomas of the

liver. These hormonally responsive tumors can cause fatal hemorrhage. They
usually regress when COC use is discontinued; risk is related to prolonged
use (Berek, 2002).
Possible contraindications:
- Absolute contraindications:
(1) Thrombophlebitis or thromboembolic disorder (or history there of).
(2) Cerebrovascular accident (or history there of).
73
lactation
(3) Coronary artery or ischemic heart disease (or history there of).
(4) Known or suspected estrogen dependent neoplasia (or history there of).
(5) Known or suspected breast carcinoma (or history there of).
(6) Pregnancy.
(7) Benign or malignant liver tumor (or history there of).
(8) Known impaired liver function at present time.
(9) Previous cholestasis during pregnancy (Hatcher et al., 2004).
- Strong relative contraindications:
(10) Severe headaches, particularly vascular or migraine headaches which

start after initiation of oral contraceptives.
(11) Hypertension with resting diastolic BP of 90 mmHg or greater or a

resting systolic BP of 140 mmHg or greater on three or more separate visits,
or an accurate measurement of 110 mmHg diastolic or more on a single
visit.
(12) Mononucleosis, acute phase:
(13) Effective major surgery or major surgery requiring immobilization

planned in next four weeks.
(14) Long leg cast or major injury to lower leg.
74
lactation
(15) Over 40 years old, accompanied by a second risk factors for the
development of cardiovascular disease (such as diabetes or hypertension).
(16) Over 35 years old and currently a heavy smoker (15 or more cigarettes
a day).
(17) Abnormal bleeding (Hatcher et al., 2004).
- Other considerations that may suggest that pills are not the ideal
contraception:
■ Lactation.
■ Diabetes prediabetes or a strong family history of diabetes.
■ Sickle cell disease or sickle C disease.
■ Active gall bladder disease.
■ Congenital hyperbilirubinemia.
■ Undiagnosed abnormal genital bleeding.
■ Over 50 years old.
■ Completion of term pregnancy within past 10-14 days.
■ Weight gain of 10 pounds or more while on the pill.
■ Cardiac or renal disease (or history there of).
■ Family history of hyperlipidemia.
75
lactation
■ Conditions likely to make patient unreliable at following pill instruction

(mental retardation, major psychiatric illness, alcoholism or other chemical
abuse, history of repeatedly taking oral contraceptives or other medication
incorrectly).
■ Family history of death of a parent or sibling due to myocardial infarction

before the age of 50. Myocardial infarction in a mother or sister especially
significant and indicates a need for lipid evaluation (Hatcher et al., 1998).
Pill danger signs:
Any one of these 5 symptoms may mean that you are in serious trouble:
■ Abdominal pain (severe).
■ Chest pain (severe) cough or shortness of breath.
■ Eye problems (vision loss or blurring), speech problems.
■ Severe leg pain (calf or thigh) (Hatcher et al., 1998).
See your clinician if you have any of these problems or if you

develop depression, yellow jaundice or a breast lump. If you smoke more
than 14 cigarettes a day, you should be especially careful to watch out for
the pill danger signs, and you should probably stop taking pills at age 35.
Better yet, stop smoking (Hatcher et al., 1998).
76
lactation
*Once-a-month injectable contraceptives:
A number of once-a-month injectable contraceptives have been

studied over the last 30 years and at least three different formulations are
currently in use worldwide. Each of these formulations contains an ester of
the natural estrogen, estradiol, and a synthetic progestin. This is in contrast
to the COCs which contain synthetic analogs of both estradiol and
progesterone. Because it contain both an estrogen and a progestin, the
precautions related to their use are similar to those of COCs; however, since
the estrogen component is a natural estrogen, administration is parenteral
and the circulating levels reach peaks that are in the range of those of the
normal preovulatory phase of the menstrual cycle, some of these precautions
may be very conservative (Dorflinger, 1994).
Contraindications:
Current or suspected pregnancy, and estrogen-responsive tumors of

the breast or genital tract (Dorflinger, 1994).
Precautions:
Primary precautions are conditions under which a woman should

probably not use monthly injectables, but if she does, she should be
monitored closely. These include current or individual history of
cardiovascular disease, current liver disease or liver tumors and over age 40
if a smoker (Dorflinger, 1994).
77
lactation
Secondary precautions to use are those which should be considered

very carefully and balanced against the risks of not using the particular
method. These include suspicion of breast or genital tract cancer until cancer
is ruled out, unexplained abnormal vaginal bleeding, use of drugs which
might affect metabolism and decrease effective levels of circulating steroids,
breastfeeding, and having combinations of several risk factors for
cardiovascular disease (Dorflinger, 1994).
These precautions are categorized as proposed, based on the fact

that most women in the developing world face a risk from pregnancy that is
probably far greater than the risks from any of the present formulations of
steroidal contraceptives (Dorflinger, 1994).
(F) Fertility Awareness Methods (FAM)
Fertility awareness is a method for planning or preventing

pregnancies by identifying the fertile days of a woman’s menstrual cycle
Contraindications:
Some women do not exhibit the signs and symptoms of the

menstrual cycle that must be monitored to determine fertile days, and others
have irregular cycle that make the method unreliable. The method is also
contraindicated for women who are
• Lactating.
78
lactation
• Contraceptive users.
• Ill with diseases that affect signs and symptoms of the menstrual cycle.
• On certain medication such as douching and spermicide.
• Near menopause (Population Reports, 1996).
Disadvantages:
• Requires reliable, committed user.
• Requires thorough training that could be expensive.
• Users may not comply with abstinence.
• Signs and symptoms differ from woman to woman and from cycle to cycle.
• Failure rates higher than for other contraceptive methods.
• Method requires diligent monitoring (Brueggemann, 1997).
Fertility Awareness Methods are:
a) Calendar Method:
This method is particularly unreliable for women whose cycles are

irregular (Hatcher et al., 1998).
b) Cervical Mucus Method.
79
lactation
c) The Basal Body Temperature Method:
The temperature may drop slightly about 12-24 hours before

ovulation. After ovulation, the temperature rises 0-2 Celsius to 0.5 Celsius.
Because body temperature responds to many stimuli, the interpretation of
the temperature pattern requires cautious judgment (Population Reports,
1996).
d) Symptothermal Method:
The symptothermal method combines measurements of basal body

temperature with observations of vaginal discharge and other common
symptoms; mid cyclic pain, spotting and mastalgia (Hatcher et al., 1998).
e) Coitus Interrupts:
A couple using the withdrawal method may have sexual

intercourse until ejaculation is impending, at which time ejaculation should
occur completely away from the vagina and the external genitalia of the
female (Hatcher et al., 1998).
f) Abstinence:
Introduction:
Abstinence is defined by some as refraining from all sexual

behavior, including masturbation; by some as refraining from sexual
80
lactation
behavior involving genital contact; and by others as refraining from

penetrative sexual practices (Hatcher et al., 1998).
Giving and receiving sexual pleasure without penetration is an

important part of sexual expression for both men and women and is effective
in decreasing the risk of STI and pregnancy (Black et al., 2004).
Efficacy:
If the goal of abstinence is to avoid unwanted pregnancy, this

method is very effective and allows people to be involved in other forms of
sexual expression without increasing the risk of pregnancy (Black et al.,
2004).
Indications:
Primary abstinence (i.e., abstaining from some or all sexual

behavior by a person who has not yet been sexually active) is not uncommon
among young people. Indeed, people of all ages deliberately choose to
abstain at a number of times throughout their lives (Hatcher et al., 1998).
Contraindications:
Both partners in a relationship should choose this method to avoid

frustration on the part of one (Black et al., 2004).
Non-Contraceptive Health Benefits:
• Freedom from the threat of STI and HIV infection if there is no exchange
of body fluids
81
lactation
• No physical side effects
• No need to visit a health-care provider. However, healthcare providers can

offer valuable support, information, and alternative options should
individuals wish to consult about this method
• No cost, unless condoms and dams are used (Black et al., 2004).
Risks and Side effects:
Risks and side effects include concern that abstinence
• may be too restrictive for some couples.
• does not encourage the use of other methods of contraception, if behavior

patterns change (Black et al., 2004).
g) Post Coital Contraception:
As long as condoms break, women are raped, diaphragms and

cervical caps are dislodged, IUDs are expelled and pills are lost or forgotten,
we will need morning-after birth control (Hatcher & Kowal, 2000).
Post coital methods currently used include:
● Combined birth control pill regimen: 2 pills (oral) taken within 72 hours
of unprotected intercourse and 2 more pills taken 12 hours later (Hatcher et
al., 2004).
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lactation
● Morning after IUD insertion: A Cu IUD inserted up to 5 days after

unprotected intercourse (Hatcher et al., 1998).
83

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7-Chapter I

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Chapter I Contraceptive methods used during

It is well accepted that breastfeeding contributes significantly to

Adequate postpartum contraception is recommended in order to

contraceptives, ideally initiated after six weeks or earlier in special situations

The available contraceptive methods are:

1- Hormonal contraception will be presented in two parts:

- Progestin only contraceptives: progestin only pill, implants and

- Combined oral contraceptives “the pill”.

4- Spermicides and vaginal barrier methods.

5- Natural methods: Abstinence and coitus interrupts.

6- Fertility awareness methods:

- Basal body temperature.

- Cervical mucus method.

7- Voluntary surgical contraception.

(A) Lactational Amenorrhea Method (LAM)

Background and Biological Basis:

In 1988, researchers from several centers around the world met to

LAM has three criteria:

Defined as the absence of the menses. Menses return is defined as

2. Less than six months postpartum (Labbok et al., 1994).

3. Fully or nearly fully breastfeeding:

Both the frequency and intensity of breastfeeding reduce the

(2) A higher frequency of suckling episodes per hour (about 5) each

lasting only about 3 minutes (Fathalla et al., 1990).

A reduction from full breastfeeding to breastfeeding supplemented

The effectiveness of LAM has been demonstrated in clinical trials

If an amenorrheic woman is separated from her infant and

A Cochrane literature review on efficacy in 2003 was carried out

Optimal Breastfeeding Behaviors for Child Health and

• Begin breastfeeding as soon as possible after the child is born.

• Breastfeed exclusively for the first six months.

• Breastfeed frequently, whenever the infant is hungry, day and night.

• Continue breastfeeding even if the mother or the baby becomes ill.

• Avoid using a bottle, pacifiers or other artificial nipples.

• Eat and drink sufficient quantities to satisfy the mother's hunger.

• Continue to breastfeed up to two years and beyond (Labbok et al.,

Breast-feeding still prevents more pregnancies than all modern

dopamine production, resulting in increased pituitary prolactin secretion.

LAM may be appropriate beyond 6 months or if the infant is

Breastfeeding is best for both mothers and babies and should be

(B) Intrauterine Devices (IUDs)

IUDs are devices inserted into the uterine cavity to prevent

IUDs cause formation of a ”biological foam" within the uterine

Copper IUDs (Cu IUDs) continuously release a small amount of

The use of IUDs is highly effective in preventing pregnancy and it

Prevalence of IUDs use in developing countries:

Currently, the mix of available methods has greatly expanded and

The variety of country situations with regard to IUD use can be

In Egypt, a National Commission on Population was created in

In women using an IUD, sensitive assays for human chorionic

In 1997, a review suggested that effects that occur after fertilization

But this conclusion was disputed for Cu IUDs (Sivin, 1997 -

Understanding the mechanisms of action of the IUD in humans is

The possible prefertilization mechanisms of action of the IUD

The majority of women who are wearing hormonally active IUDs

The possible postfertilization mechanisms of action of the IUD

The altered intrauterine environment interferes with sperm passage

Sperm transport through the cervical mucus and the

Cu IUDs raise the copper concentration of cervical mucus

Biochemical evidence for fertilization:

The earliest available biochemical marker of fertilization in

A rigorous examination of the evidence on the mechanism of

In 1997, the World Heath Organization (WHO) published the