Overview of Contraceptive Methods

1. Overview of Contraceptive Methods

2. Session Objectives At the end of this session, the participants will be able to: Identify how contraceptive methods physiologically work on the male and female reproductive system Compare and contrast, using reference materials, mechanism of action, advantages, disadvantages, special issues and instructions for each contraceptive method presented Identify contraceptive methods for birth spacing versus birth limiting Become familiar with the �Decision Making Tool for FP Clients and Providers�

3. Outline of Presentation Overview of FP methods Latest information/new findings about various FP methods

4. Oral Contraceptives- Combined oral contraceptives- Progestin- only contraceptives

5. Pills Have Changed Over Time New pills are safer due to reduced hormonal dose (oestrogen) and generation of synthetic hormones Typical dosages by year (approximate) - 1960s: 1970s: 50 mcg of ethinyl estradiol - 1980s: 1990s: 30 mcg of ethinyl estradiol - Present: 20 mcg of ethinyl estradiol New generation of synthetic hormones -Desogestrel, dropirenone

7. COCs: Mechanism of action Contain estrogen and progestin Taken every day � orally 1. Combined action hampers production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) ---? ovulation is suppressed 2. Creates thick cervical mucus which hampers sperm penetrability 3. Creates thin endometrium preventing implantation

8. Non Contraceptive Benefits and Advantages Non contraceptive Benefits Reduce the risk of: - benign breast disease - ovarian & endometrial cancer - functional ovarian cysts - ectopic pregnancy - symptomatic PID Menstrual improvements (regularity and flow) Advantages Can be stopped any time Highly effective, reversible, easy to use Easily available Safe for most women Client controlled

9. Disadvantages of COCs Client dependant � must be taken every day Requires regular, dependable supply Minor side effects in some clients May cause rare but serious circulatory system complications especially in women > 35 who smoke and/or have other health problems No protection from STIs/HIV

10. Appropriate users of COCs Women requesting an effective reversible method Nulliparous women Irregular menstrual cycles Anemia due to heavy menstrual bleeding History of ectopic pregnancy Family history of ovarian cancer, history of benign, functional ovarian cysts

11. Progestin-Only Pills (POPs): Characteristics Especially suitable for breastfeeding women and others who should not use estrogen

12. Mechanism of action Thickens cervical mucus and creates thin endometrium � hampering sperm transport Suppresses ovulation in ALL cycles Effectiveness Pregnancy rate < 1 %Effectiveness Pregnancy rate < 1 %

13. Key Counseling Topics for POP Users Safety and efficacy How POPs work Possible side effects How to take pills and what to do when pills are missed How to obtain and use back-up methods and emergency contraception No protection from STIs

15. Pill Packs to be Given � Initial and Return Visit Provide one year�s supply, depending upon woman�s desires and anticipated use. Balance maximum access to pills with contraceptive supply and logistics The re-supply system should be flexible, so that the woman can obtain pills easily in the amount and at the time she requires them. Source: WHO, Selected Practice Recommendations for Contraceptive Use, 2002.

16. Client Access and Availabilityto Oral Contraceptives Use many types of trained providers Use less formal approaches such as community-based services: - health structure linkage desirable - initial screening checklists useful - training and supervision necessary - educational materials recommended - Functional re-supply system needed

17. Injectables- Combined injectables- Progestin- only injectables

18. Combined Injectable Contraceptives Contain progestin and estrogen Used by over 1 million women worldwide Administered monthly Provide more regular bleeding cycles May result in estrogen-related side effects

21. DMPA: Advantages Safe Highly effective Easy to use Long-acting Reversible Can be discontinued without providers help Can be provided outside of clinics Require no action at time of intercourse Use can be private Has no effect on lactation Has non contraceptive health benefits

22. DMPA: Disadvantages Causes side effects: Menstrual changes Weight gain Headache, dizziness and mood change Action cannot be stopped immediately Causes delay in return to fertility Provides no protection against STIs including HIV

23. Return to Fertility AfterStopping DMPA Use This slide shows a delay in the return of fertility after stopping DMPA use, as compared with oral contraceptives and IUDs. However, the pregnancy rates become the same for all methods after 24 months. There is no permanent damage to fertility due to DMPA use. This slide shows a delay in the return of fertility after stopping DMPA use, as compared with oral contraceptives and IUDs. However, the pregnancy rates become the same for all methods after 24 months. There is no permanent damage to fertility due to DMPA use.

25. DMPA Effect to fetus and Breastfeeding No harmful effect on fetus No effect on later development of child No effect on: Onset or duration of lactation Quantity or quality of breast milk Health and development of infant When to initiate After child is 6 weeks old (preferred)

26. Effect of DMPA on Bone Density DMPA users have lower bone density than non-users, in most studies Those initiating as adults regain most lost bone Long-term effect in adolescents unknown Concern that osteoporosis may develop later long-term studies are needed Generally acceptable to use

27. New DMPA Subcutaneous depot-medroxyprogesteronde (DMPA-SC) (depo-subQ provera 104) Low dose formulation Injected into the tissue just under the skin with a finer, shorter needle Slower and more sustained absorption 30% lower dose of progestin(104mg /150mg)

28. Implants Norplant� Jadelle� Implanon�

29. Implants Norplant�: 6 capsules, effective 7 years 1-yr failure rate 0.05% (1 pregnancy / 2000 users) 5-yr failure rate 1.6% Jadelle� 2 rods, effective 5 years 1-yr failure rate 0.05%; 5-yr failure rate 1.1% Implanon� 1 rod, effective 3 years

30. Norplant

31. Jadelle�

32. Implanon�

34. Important Programmatic Characteristics of IUDs Highly effective/comparable to FS �Reversible sterilization� 12-13 yrs with CU-T Cheaper and easier to provide Quickly and completely reversible (much easier to reverse than FS or V) Very safe for most women (including: PP, PA, or interval; BF; young; nulliparous) More service cadres can provide(because non-surgical) Greater availability = greater choice Good option for HIV+ women Most cost-effective method (potentially) These are some of the most important method-specific, i.e., intrinsic characteristics of the IUD, that make it an important method to be available for programs and service providers, and that make it a good potential choice for many women. Our challenge, of course, as change agents working for change agencies is to translate and transmit these method-specific facts and characteristics�and the important recent findings about their even greater safety than had previously been thought�into accurate perceptions and appropriate contraceptive behaviors in the programs and countries we assist. _______ First bullet: efficacy approaches FS, cheaper, easier to provide and reverse: In effect: �Reversible sterilization��but in quotes because this is not ever how we�d promote it because of inevitable misconceptions and problems that would cause�but it certainly is �food for programmatic thought� These are some of the most important method-specific, i.e., intrinsic characteristics of the IUD, that make it an important method to be available for programs and service providers, and that make it a good potential choice for many women. Our challenge, of course, as change agents working for change agencies is to translate and transmit these method-specific facts and characteristics�and the important recent findings about their even greater safety than had previously been thought�into accurate perceptions and appropriate contraceptive behaviors in the programs and countries we assist. _______ First bullet: efficacy approaches FS, cheaper, easier to provide and reverse: In effect: �Reversible sterilization��but in quotes because this is not ever how we�d promote it because of inevitable misconceptions and problems that would cause�but it certainly is �food for programmatic thought�

35. Dispelling Myths About IUDs are not abortificients do not cause infertility are unlikely to cause discomfort for male partner do not travel to distant parts of body are not too large for small women

36. Medical Evidence: Low PID Rates among IUD Users WHO study 23,000 insertions; 51,000 years follow-up Overall PID rate: 1.6 per 1000 women per year (i.e., 998.4/1000 women did not get PID) First 20-days: highest risk Later periods: PID risk same as if no IUD Mainly in China, so � Mainly in China, so �

37. Medical Evidence: IUD Use Not Associated with Infertility Mexico: nulligravid infertile and primigravid women Similar patterns of previous copper IUD use Blood tests for chlamydial antibodies Infertile women: twice the % of antibodies Thus, the real �culprit�: Chlamydia trachomatis (and GC), not the IUD

38. Medical Evidence: No Risk of HIV Acquisition from IUD

39. WHO Medical Eligibility Criteria: HIV/AIDS and Copper IUDs More HIV categories, only 3 is initiating � What is this new evidence? More HIV categories, only 3 is initiating � What is this new evidence?

40. New IUDs & feature

41. Summary IUDs are: Safe, effective, convenient, reversible, long-lasting, cost effective, easy-to-use Providers can ensure safety by: Careful screening Informative counseling Aseptic insertion Proper follow-up

42. Vasectomy No-scalpel technique (preferred) Incisional

43. Vasectomy Effectiveness Comparable to Female Sterilization, implants, IUDs Not effective immediately�WHO now recommends use of backup contraception for 3 months after the procedure (i.e., no longer � � or 20 ejaculations�). Failure (pregnancy) commonly quoted at from 0.2% to 0.4%, but rates as high as 3-5% have been reported. �Counseling implications � Failure may be due to client behavior (when alternative contraception is not used after the procedure) or to failure from the technique itself. Failure may be due to client behavior (when alternative contraception is not used after the procedure) or to failure from the technique itself.

44. Vasectomy Safety Very safe, with few medical restrictions Major morbidity and mortality rare Adverse long-term effects has not been found. Minor complications (e.g., infection, bleeding, post-operative and/or chronic) pain 5-10%. No-scalpel (NSV) technique has lower incidence of bleeding and pain than incisional technique. No long term association with testicular / prostate cancer or cardiovascular disease No HIV/STD protection

45. Vasectomy:Salient Programmatic Facts Men in every region, cultural, religious and SE setting show interest in vasectomy, despite common assumptions about negative male attitudes or societal prohibitions. However, men often lack full access to information and services, especially male-centered programming, which has been shown to result in greater uptake of vasectomy.

46. Female Sterilization (FS) Approaches: Transcervical (through hysteroscopy) Chemicals e.g. Quinacrine Plugs e.g. Adiana procedure Microcoils e.g. Essure Tubal ligation Laparotomy Minilaparotomy Laparoscopic

47. Female Sterilization: Effectiveness Highly effective, comparable to vasectomy, implants, IUDs No medical condition absolutely restricts a person's eligibility for FS Risk of failure (pregnancy), while low; continues for years after the procedure does not diminish with time is higher in younger women Cumulative pregnancy rates: at 1 year, 5.5/1000 procedures (994.5/1000 women protected) at 5 years, 13/1000 18.5/1000 at 10 years reported, i.e.,almost 2/100 became pregnant during that interval (982.5/1000 didn�t) Though pregnancy very uncommon, 1/3 ectopic (e.g., at 10 years, 6 ectopics / 1000 women who underwent FS)

48. Condoms

49. Overview: HIV/AIDS Status and Contraceptive Eligibility Criteria

50. Condoms, WHO Eligibility Criteria The WHO Medical Eligibility Criteria classify the conditions: HIV-infected, the presence of AIDS and use of ARV therapy as category 1 for condom use. Male and female condoms are the only methods that can prevent HIV transmission to partners as well as transmission of other STIs between partners. They also might prevent transmission of a different HIV strain to a woman who is already infected with HIV. Even when a woman's HIV infection is effectively controlled by ARVs and she is therefore unlikely to transmit HIV, she still should be encouraged to use condoms routinely. The WHO Medical Eligibility Criteria classify the conditions: HIV-infected, the presence of AIDS and use of ARV therapy as category 1 for condom use. Male and female condoms are the only methods that can prevent HIV transmission to partners as well as transmission of other STIs between partners. They also might prevent transmission of a different HIV strain to a woman who is already infected with HIV. Even when a woman's HIV infection is effectively controlled by ARVs and she is therefore unlikely to transmit HIV, she still should be encouraged to use condoms routinely.

51. What is Dual Protection? A strategy to protect against HIV/STIs and pregnancy through: use of condoms alone for both purposes use of condoms plus another FP method or EC (dual method use) the avoidance of risky sex, e.g.: abstinence avoidance of all types of penetrative sex mutual monogamy between uninfected partners combined with a contraceptive method for young people, delaying sexual debut

52. Difference Between Dual Protection and Dual Method Use Dual method use is use of any effective contraceptive for preventing pregnancy with an additional effective method for protection against STIs including HIV. Usually, male or female condom is used. -----? Use of condoms to protect against STI/HIV and another method to prevent pregnancy Reduces: transmission of HIV to uninfected partner transmission of a different strain of HIV to a partner with HIV infection risk of acquiring or transmitting other STIs risk of unplanned pregnancy

53. Effectiveness of Condoms as Contraceptives Must be used consistently and correctly �typical use,� pregnancy rate: 14-21% (one in 5 to one in 7 users, on average, will become pregnant in 1 yr) [even with] �perfect use,� pregnancy rate 3-5% In public health programs (i.e., across populations), �perfect use� is not a realistic consideration Male and female condoms are the only contraceptive method that can prevent both pregnancy and sexually transmitted infections. To be highly effective, however, they must be used consistently and correctly. When used correctly every time a couple has intercourse, the male condom has a pregnancy rate as low as 3 percent and the female condom � 5 percent. But condoms are often not used consistently and may be used incorrectly. In common use, their pregnancy rate is much higher -- around 14 percent for the male condom and 21 percent for female condom. Male and female condoms are the only contraceptive method that can prevent both pregnancy and sexually transmitted infections. To be highly effective, however, they must be used consistently and correctly. When used correctly every time a couple has intercourse, the male condom has a pregnancy rate as low as 3 percent and the female condom � 5 percent. But condoms are often not used consistently and may be used incorrectly. In common use, their pregnancy rate is much higher -- around 14 percent for the male condom and 21 percent for female condom.

54. Correct Use of theMale Condom

55. Female Condom

56. Lactational Amenorrhea Method LAM

57. Lactational Amenorrhea Method (LAM) is a Highly Effective Method LAM criteria: Menses not yet returned Infant less than six months Woman fully or nearly fully breastfeeding If any criteria change, start another method.

58. LAM Advantages Universally available At least 98% effective No commodities/supplies required Bridge to other contraceptives Improves breastfeeding and weaning patterns Postpones use of hormones until infant more mature

59. Recommended Breastfeeding Behavior A mother should breastfeed: Soon after delivery Without supplementation up to 6 months Before any supplemental feeding Frequently, upon request, not on schedule Without bottles or pacifiers Without long intervals between feeds both day and night While maintaining a good diet for herself.

60. Postpartum Contraceptive Options This slide shows all the postpartum contraceptive options available and their recommended time of initiation. Follow carefully each one of the three categories of women. This slide shows all the postpartum contraceptive options available and their recommended time of initiation. Follow carefully each one of the three categories of women.

61. HIV Infection Avoid breastfeeding if replacement feeding is acceptable, feasible, affordable, sustainable and safe. If not possible, excusive breastfeeding is recommended during the first month of life and should then be discontinued as soon as it is feasible. Counseling including risks and benefits of various infant feeding options based on local assessments, guidance in selecting the most option for their situation.

62. Fertility Awareness-Based Methods/Natural Family Planning (NFP)

63. Definition of NFP: A variety of methods used to plan or prevent pregnancy based on identifying the woman�s fertile days

64. Characteristics of NFP

65. Three categories of natural methods Withdrawal: removing penis before ejaculation Calendar-based methods Calendar Method(Rhythm/Safe Days/Ogino-Knaus Method) Standard Days Method Observation-based methods Ovulation/Cervical Mucus/Billing Ovulation Method (BOM) The TwoDay Algorithm Basal Body Temperature(BBT) Sympto-thermal Method

66. Natural Family Planning (NFP) Methods Avoiding unprotected intercourse during the fertile days is what prevents pregnancy Provide an acceptable alternative to diverse population groups with varied religious, medical, personal and ethical beliefs Depend on couple�s ability to identify the fertile phase of each menstrual cycle and their motivation and discipline to practice abstinence when required May be used in combination with other methods where couple use barrier methods only during the fertile period. Couples who wish to achieve pregnancy can improve their chances of conception if they can recognize the fertile phase of the cycle

67. NFP Protection Rate Failure rate � 10-30 pregnancies per 100 users per year. WHO studies and others have found that when properly used, NFP methods result in a pregnancy rate of only 3%. NFP, Expanding Options, Institute of Reproductive Health, Georgetown University Medical Center Approximately 15% of FP users worldwide report using a natural method (IPPF Medical Bulletin Volume 34 Number 3 June 2000)

68. Scientific Basis of NFP Research has shown that a woman is able to get pregnant during only a few days of her menstrual cycle, for up to 5 days prior to ovulation (Lifespan of spermatozoa), at the time she ovulates and for about one day afterwards (Lifespan of an ova). Women usually ovulate 14 days prior to the 1st day of the next menstrual cycle.

69. Other Signs of Fertility Breast tenderness Changes in the position, texture and opening of the cervix Mid-cycle pain or bleeding that may accompany ovulation Nausea

70. Advantages No physical side effects Opportunity for couples to learn more about their sexual physiology and gain a better understanding of their reproductive function Responsibility for family planning is shared by both partners, which may lead to increased communication and cooperation between them Service providers not required after training No cost after training Enhanced communication and intimacy For some, the ability to adhere to religious and cultural norms.

71. Disadvantages Highly dependent on the commitment and cooperation of both partners Low use-effectiveness Relatively long initial training is needed Daily monitoring and recording of signs of fertility may be bothersome to some women Long periods of sexual abstinence may cause marital difficulties and psychological stress Women who have irregular cycles find the method difficult to use Signs and symptoms which may predict fertility are highly variable during breast feeding

72. Contraceptive Failure User-Directed Methods If these rates are compared with the failure rates of other methods that also rely on the user, we can see that the Standard Days Method has a similar effectiveness as a number of other methods (for example, condoms) and that it is more effective than some methods currently available in family planning programs (such as spermicides). The studies on which these rates are based are not necessarily comparable with each other, because of differences in their design and the methodology for data analysis. However, this gives us a general idea how the effectiveness of different methods compare. If these rates are compared with the failure rates of other methods that also rely on the user, we can see that the Standard Days Method has a similar effectiveness as a number of other methods (for example, condoms) and that it is more effective than some methods currently available in family planning programs (such as spermicides). The studies on which these rates are based are not necessarily comparable with each other, because of differences in their design and the methodology for data analysis. However, this gives us a general idea how the effectiveness of different methods compare.

73. Special Situations Adolescents � frequent anovular cycles which make learning and practicing NFP difficult in addition to unscheduled/unplanned sexual encounters. Pre-menopausal women � ovulation becomes erratic during the last few years of reproductive health (anovular and irregular cycles) Postpartum � The signs of return to fertility may be difficult to interpret leading to the need for prolonged abstinence. NFP is not appropriate for these situations NFP is not appropriate for these situations

74. Standard Days Method The Standard Days Method is a new family planning method. It was developed and tested by researchers at the Institute for Reproductive Health at Georgetown University. The Standard Days Method meets the need for a natural method that can be integrated easily into public and private reproductive health programs. The Standard Days Method is a new family planning method. It was developed and tested by researchers at the Institute for Reproductive Health at Georgetown University. The Standard Days Method meets the need for a natural method that can be integrated easily into public and private reproductive health programs.

75. The Standard Days Method Identifies days 8 - 19 of the cycle as fertile. Is for women with menstrual cycles between 26 and 32 days long. Helps a couple avoid unplanned pregnancy by knowing which days they should not have unprotected intercourse. A client can use a color - coded string of beads to help her keep track of where she is in her cycle and know when she is fertile. Let�s begin with what is the Standard Days Method and how does it work. The Standard Days Method identifies days 8 -- 19 of the menstrual cycle as the fertile days, when there is a significant probability of pregnancy. On all the other days of the cycle, pregnancy is most unlikely. The method works best for women who have cycles between 26 and 32 days long. Therefore, to use the Standard Days Method to prevent pregnancy, couples avoid unprotected intercourse from day 8 through day 19 of each cycle. On all the other cycle days, they can have unprotected intercourse. To help them keep track of the woman�s cycle days, and to know which days she can get pregnant, many couples use a simple visual aid- CycleBeads�.Let�s begin with what is the Standard Days Method and how does it work. The Standard Days Method identifies days 8 -- 19 of the menstrual cycle as the fertile days, when there is a significant probability of pregnancy. On all the other days of the cycle, pregnancy is most unlikely. The method works best for women who have cycles between 26 and 32 days long. Therefore, to use the Standard Days Method to prevent pregnancy, couples avoid unprotected intercourse from day 8 through day 19 of each cycle. On all the other cycle days, they can have unprotected intercourse. To help them keep track of the woman�s cycle days, and to know which days she can get pregnant, many couples use a simple visual aid- CycleBeads�.

76. How to use the beads Each day the woman moves a small tight-fitting rubber ring along the necklace. The 1st day of the cycle is represented by a red bead. On the 1st day of her menstrual bleeding, she places the rubber ring on the red bead. She moves the ring one bead each day. The brown beads represent her infertile days and the white beads represent her fertile days

77. Efficacy of the SDM The pregnancy rates are as follows: Considering all the pregnancies that occurred in cycles in which the woman reported that she did NOT have intercourse during days 8 through 19, the 1-year pregnancy rate was 4.7 pregnancies per 100 woman years of method use. This is considered the correct-use pregnancy rate. Considering all these pregnancies, plus the pregnancies that occurred in cycles in which the woman had intercourse during days 8 through 19 but used another method (such as condoms or withdrawal), the 1-year pregnancy rate was 5.6 pregnancies per 100 woman years of method use. This reflects the failure of the Standard Days Method, plus the failure of the additional method. Considering all pregnancies, including those that occurred in cycles in which the woman had unprotected intercourse on day 8 through 19 (that is, both correct and incorrect use of the method), the 1-year pregnancy rate was 11.9 pregnancies per 100 woman years of method use. This reflects that when women have unprotected intercourse during days 8 through 19, they are very likely to become pregnant. All these rates were calculated using single decrement life table analysis, with multiple exclusion. Results of the study were published in the May 2002 issue of the medical journal �Contraception�. The pregnancy rates are as follows: Considering all the pregnancies that occurred in cycles in which the woman reported that she did NOT have intercourse during days 8 through 19, the 1-year pregnancy rate was 4.7 pregnancies per 100 woman years of method use. This is considered the correct-use pregnancy rate. Considering all these pregnancies, plus the pregnancies that occurred in cycles in which the woman had intercourse during days 8 through 19 but used another method (such as condoms or withdrawal), the 1-year pregnancy rate was 5.6 pregnancies per 100 woman years of method use. This reflects the failure of the Standard Days Method, plus the failure of the additional method. Considering all pregnancies, including those that occurred in cycles in which the woman had unprotected intercourse on day 8 through 19 (that is, both correct and incorrect use of the method), the 1-year pregnancy rate was 11.9 pregnancies per 100 woman years of method use. This reflects that when women have unprotected intercourse during days 8 through 19, they are very likely to become pregnant. All these rates were calculated using single decrement life table analysis, with multiple exclusion. Results of the study were published in the May 2002 issue of the medical journal �Contraception�.

78. Who Can Use This Method? Although the Standard Days Method is appropriate for most women, there are several requirements that a woman interested in using the method should meet to achieve successful use: The majority of her cycles should be between 26 and 32 days. If a woman does not know the approximate length of her menstrual cycles, this can be determined by a few simple questions. If her cycles usually last between 26 and 32 days, the woman will have approximately 95% protection from pregnancy if she uses the method correctly. While she is using the method, CycleBeads will help her know if her cycles are within this range. If she has 2 cycles outside this range during a year, her probability of pregnancy will be more than 5%, and she should be encouraged to use another method. She and her partner should be able to use the method together. The collaboration of the man is extremely important for the successful use of the method. He needs to understand and accept that on days 8 through 19 of each cycle, they will need to use a condom or not have intercourse. If the man (or the woman) insists on having unprotected intercourse during the fertile days, they should be encouraged to use another method. She should not be at risk of sexually transmitted infections. If either member of the couple is exposed to the risk of sexually transmitted infections, the Standard Days Method is not appropriate for them. Condoms are the only method that provide protection from these infections. Although the Standard Days Method is appropriate for most women, there are several requirements that a woman interested in using the method should meet to achieve successful use: The majority of her cycles should be between 26 and 32 days. If a woman does not know the approximate length of her menstrual cycles, this can be determined by a few simple questions. If her cycles usually last between 26 and 32 days, the woman will have approximately 95% protection from pregnancy if she uses the method correctly. While she is using the method, CycleBeads will help her know if her cycles are within this range. If she has 2 cycles outside this range during a year, her probability of pregnancy will be more than 5%, and she should be encouraged to use another method. She and her partner should be able to use the method together. The collaboration of the man is extremely important for the successful use of the method. He needs to understand and accept that on days 8 through 19 of each cycle, they will need to use a condom or not have intercourse. If the man (or the woman) insists on having unprotected intercourse during the fertile days, they should be encouraged to use another method. She should not be at risk of sexually transmitted infections. If either member of the couple is exposed to the risk of sexually transmitted infections, the Standard Days Method is not appropriate for them. Condoms are the only method that provide protection from these infections.

79. Two Day Method

80. Two Day Method Relies on a simple algorithm to help women identify when they are fertile based upon the presence or absence of cervical secretions. TwoDay method users are taught to consider all secretions noticeable at the vulva as a sign of fertility(irrespective of color, consistency, stretchiness, or any other characteristic. They pay attention to their secretions in the afternoon and evening to avoid potential confusion with seminal fluids which may have been deposited the previous evening or early in the morning.

82. Conditions Requiring Careful Consideration The need for highly effective protection against pregnancy Inability to comply with sexual abstinence as required by the method Irregular cycles Breast feeding

83. For once, let�s begin, in talking about contraception, with men, and with the most underutilized of the major methods, vasectomy. For once, let�s begin, in talking about contraception, with men, and with the most underutilized of the major methods, vasectomy.

84. What is Emergency Contraception? Methods of preventing pregnancy after unprotected sexual intercourse Regular OCs, used: in a special higher dosage within 72 hours (3 days) of unprotected sex IUDs can also be used for up to 5 days after unprotected sex ECPs cannot interrupt an established pregnancy Regular birth control pills used in a special higher dosage. ECPs are a higher dosage of the same hormones found in daily birth control pills Used within 120 hours of unprotected sex (but as soon as possible after unprotected sex) IUDs can also be used for up to 7days after unprotected sex Distinct from RU486 (The Abortion Pill) EC is only method that can be used after unprotected sex to prevent pregnancy Millions of unintended pregnancies and abortions could be averted with EC. Worldwide unintended pregnancies lead to at least 20 million unsafe abortions each year, and the death of some 80,000 women Regular birth control pills used in a special higher dosage. ECPs are a higher dosage of the same hormones found in daily birth control pills Used within 120 hours of unprotected sex (but as soon as possible after unprotected sex) IUDs can also be used for up to 7days after unprotected sex Distinct from RU486 (The Abortion Pill) EC is only method that can be used after unprotected sex to prevent pregnancy Millions of unintended pregnancies and abortions could be averted with EC. Worldwide unintended pregnancies lead to at least 20 million unsafe abortions each year, and the death of some 80,000 women

85. Types of ECPs Progestin-only OC�s � levonorgestrel - only, in preferred regimen one dose of 1.5 mg or 2 doses of 0.75mg, 12 hrs apart ?88% reduction in risk (1/100 will get pregnant) Combined OCs: 2 doses of pills containing ethinyl estradiol (100 mcg) and levonorgestrel (0.5 mg) taken 12 hrs apart ?75% reduction in risk (2/100 will get pregnant) Progestin (levonorgestrel) -only ECPs�somewhat more effective, and side effects�N&V�less (6% vs. 23%). Sometimes specially packaged�this is what is called �Plan B� in the U.S. If nothing used after unprotected sex: 8 in 100 get pregnant If 100 women use Plan B after unprotected sex, 1 would get pregnant�an 88% reduction If 100 women use COC�s: 2 would get pregnant�75% reduction Progestin (levonorgestrel) -only ECPs�somewhat more effective, and side effects�N&V�less (6% vs. 23%). Sometimes specially packaged�this is what is called �Plan B� in the U.S. If nothing used after unprotected sex: 8 in 100 get pregnant If 100 women use Plan B after unprotected sex, 1 would get pregnant�an 88% reduction If 100 women use COC�s: 2 would get pregnant�75% reduction

86. ECPs Are Most EffectiveWhen Taken Early The need for prompt provision of ECPs must be emphasized. The important decrement in effectiveness by 72 hours indicates that prevention of implantation is an unlikely effect. Otherwise, a higher level of effectiveness would be maintained. The need for prompt provision of ECPs must be emphasized. The important decrement in effectiveness by 72 hours indicates that prevention of implantation is an unlikely effect. Otherwise, a higher level of effectiveness would be maintained.

87. Contraceptive PregnancyRates This slide shows what is currently considered the best information on contraceptive effectiveness. However, particularly for typical use rates, wide variations from program to program or from site to site may exist. This slide shows what is currently considered the best information on contraceptive effectiveness. However, particularly for typical use rates, wide variations from program to program or from site to site may exist.