Contraception - protection from conception. It is used as a means of family planning, and is also shown in cases where the prognosis of a possible pregnancy is unfavorable for a woman or an unborn child.
Protection against unwanted pregnancy, taking into account the age of the woman, the interval between births, the health status of the woman and family members, reduces gynecological morbidity and perinatal mortality. Therefore, contraception can be considered as an effective method of prevention, allowing to preserve the health of women.
There are the following methods of contraception that prevent fertilization of the egg by sperm or implantation of a fertilized egg: barrier (mechanical), spermicidal (chemical), rhythmic (physiological), interrupted sexual intercourse, hormonal, intrauterine and sexual sterilization. The first 4 methods of contraception are traditional, they were distributed before the introduction of hormonal and intrauterine contraception. The means by which the barrier, chemical, hormonal and intrauterine methods of contraception are carried out are called contraceptive methods. The degree of effectiveness of any of the methods of contraception is estimated using the Pearl index, which is equal to the number of pregnancy cases in the group of 100 women who use a specific method of contraception for 12 months.
Barrier (mechanical) methods of contraception are based on the use of tools that create a mechanical obstacle to the penetration of sperm into the cervical canal, such as condoms, the vaginal diaphragm and cervical cap. The contraceptive effectiveness of a condom is relatively low, the Pearl index is 14-18. The use of a condom can prevent infection with sexually transmitted diseases, including HIV infection.
Spermicidal (chemical) methods of contraception are based on the use of agents that are detrimental to spermatozoa. This is gramicidin paste, galascorbine (vaginal tablets). Spermicidal paste (5–6 g) is inserted into the vagina 5–10 minutes before sexual intercourse, tablets — 10–15 minutes.
Chemical contraceptives can be used with a shallow rear part of the vaginal fornix and posterior cervical deviation. If they are prone to allergic reactions, they are not recommended. Pearl Index - 20-25. Vaginal douching with solutions that have spermicidal properties, such as 2.5% acetic acid solution, 0.01% potassium permanganate solution (1 teaspoon 2% solution of potassium permanganate per 1 liter of water), 20% chloride solution can also be used for contraception. sodium, a solution of lemon juice (juice of one lemon to 0.5 liters of water). Pearl Index - 31.
The rhythmic method of contraception is based on sexual abstinence during the ovulatory period (from the 11th to the 18th day of the 28-day menstrual cycle), when conception is most likely; The Pearl index is 24. Somewhat more effective is the modification of the rhythmic method, in which sexual intercourse is allowed in the early follicular phase of the menstrual cycle and 3 days after ovulation (the Pearl index is 2 if intercourse occurs only after ovulation, and 12 if before and after ovulation) . Symptoms indicating ovulation are determined by the woman herself; These include an increase in the number of cervical mucus, an increase in rectal temperature above 37 ° C. The rhythmic method cannot be used with an irregular menstrual cycle.
Interrupted sexual intercourse - a method of contraception based on the termination of sexual intercourse before the start of ejaculation. Significant disadvantages of the method are its low efficiency (Pearl index 18 - 20), often developing with long-term use of the method of neurosis and impotence in men, pelvic pain in women.
Hormonal contraception is almost 100% effective. In women taking hormonal contraceptives, a decrease in the incidence of endometrial, ovarian and breast cancer has been reliably established. After the termination of the hormonal contraceptive generati, another function is restored within 3 to 6 months.
There are tablet (oral), intramuscularly injected and hormonal contraceptives implanted under the skin. Of these, the most common oral contraceptives (OK).
According to their composition, combined estrogen-progestin and gestagen-containing hormonal contraceptives are isolated. Combined estrogen-progestin contraceptives are OK. Known one-, two-and three-phase combined estrogen-progestin OK. Single-phase OK are tablets with a constant content of estrogen and progestin. These include non-ovlon , bisekuria, ovulen, containing in one tablet estrogens and gestagens in a ratio of 1:20 (0.05 mg and 1 mg, respectively), and second-generation drugs (riigevon) with a lower content of estrogens and gestagens in the ratio 1: 5 (0.03 mg and 0.15 mg, respectively). Single-phase OK is prescribed from the 5th day of the menstrual cycle for 21 days daily, one tablet at the same time of the day. It is unacceptable to interrupt the intake of pills, in the extreme case, the next day after the break, take two pills. The duration of the continuous reception of non-ovlon, biseurin, ovulen, rigevidona - 2 - 5 years with good portability. During this time, an obstetrician-gynecologist should examine women 1 every 3 to 6 months. With the appearance of bleeding from the genital tract while taking these drugs should be 2 to 3 days to increase the dose to 2 tablets per day. The pill is stopped when there is an acute headache, pain in the chest, legs, and also 1 month before the upcoming surgery.
The effectiveness of single-phase OC is very high, the Pearl index is less than 1. In addition, they contribute to the regulation of the menstrual cycle, reduce blood loss during menstruation, the disappearance of pain and other painful symptoms associated with menstruation, have a pronounced therapeutic effect in endometriosis of any location, fibrocystic mastopathy , hyperplasia and endometrial polyposis, ovarian follicular cysts, inflammatory diseases, especially recurrent, internal genital organs.
When using single-phase OK, complications and adverse reactions are possible. Thromboembolism (its frequency is 1: 100 000) and other diseases associated with hypercoagulation (phlebitis, thrombophlebitis) are most dangerous. The development of these complications is promoted by such factors as obesity , diabetes mellitus , smoking , hypertension , lipid metabolism disorders, and a history of severe toxicosis of pregnant women.
Contraindications to the use of these drugs are over 40 years of age (35 years for women who smoke or for III – IV degree obesity), arterial hypertension , acute liver or kidney disease, jaundice suffered during pregnancy, varicose veins or postthrombotic syndrome, a tumor localization (or suspicion of it), severe toxicosis of pregnant women in the anamnesis.
Two-phase OCs include two types of tablets, intended, respectively, for reception in the first and second phases of the menstrual cycle; the content of estrogen in them is the same, but the tablets taken in the second phase of the menstrual cycle contain more gestagens.
Three-phase OK (for example, Trisiston, Trikvilar) contain estrogens and progestogens in various combinations. In tablets of the first type, the content of estrogens and gestagens is the lowest, in tablets of the second type the dose of estrogens and gestagens increases, in tablets of the third type the content of estrogens decreases and the dose of gestagens increases. The content of estrogen and progestin in them, respectively, 0.03 and 0.05 mg, 0.04 and 0.075 mg and 0.03 and 0.125 mg. Three-phase OK is prescribed from the 1st day of the menstrual cycle for 21 days: in the first 6 days, tablets of the first type are used, then 6 days of the second type, in the next 9 days of the third type. Three-phase introduction of sex steroids Allows you to provide the same change in the content of estrogen and progestogen in the blood, as during a normal menstrual cycle.
The effectiveness of three-phase OC is very high, the Pearl index is less than 1. These drugs do not cause an increase in blood pressure, changes in the hemostasis system, or disturbances in lipid and carbohydrate metabolism. In addition, these drugs have a therapeutic affect with mastopathy, some forms of premenstrual syndrome, anovulatory menstrual cycles.
The contraceptive effect of combined estrogen-progestin OC is inhibition of ovulation due to suppression of ovulatory release of gonadotropins of the anterior pituitary gland, implantation impairment as a result of inhibition of secretory changes in the endometrium and impaired permeability of the cervical mucus in the sperm in the cervical canal.
Gestagen-containing contraceptives include the so-called mini-pili, containing microdoses of gestagens, postcoital OK and long-acting drugs.
Mini-pilli (for example, continuin, femulen) are administered continuously, daily from the first day of the menstrual cycle for 6 to 12 months. Their contraceptive action is based on the inhibition of the contractile activity of the fallopian tubes, the increase in the viscosity of mucus in the cervical canal, the disturbance of cyclic processes in the endometrium. Contraptive efficacy is slightly lower than that of estrogen-containing OC; Pearl index is 1.5 - 1. Mini-drank does not cause metabolic changes and hypertension, almost do not disrupt the activity of the blood coagulation system. A side effect that limits the use of these drugs is a disorder of the menstrual cycle - prolonged spotting that occurs in 12 to 14% of women. The use of these drugs is contraindicated in acute and chronic liver diseases, including jaundice, transferred during pregnancy.
Postcoital OK are recommended for women who have irregular sexual life (rare sexual intercourse). These include postinor containing 0.75 mg of progestogen. One tablet of the drug taken within 1 h after sexual intercourse. Contraceptive action is based on the prevention of implantation of a fertilized egg due to changes in the endometrium and its rejection in response to the decline of hormones after taking the drug. The effectiveness of postcoital OK, complications and contraindications are the same as when using mini-pile.
Gestagens containing long-acting contraceptives include medroxyprogesterone acetate and norplant . Medroxyprogesterone acetate, containing 150 mg of gestagens, is administered intramuscularly. The first injection is carried out on the 5th day of the menstrual cycle, the next - every 90 days. The contraceptive effect of this drug is associated with a decrease in permeability (increased viscosity) of cervical mucus for sperm, suppression of ovulatory release of gonadotropins, atrophic changes in the endometrium. The main side effect is a violation of the menstrual cycle (in 20% of women) - prolonged blood-like discharge, especially in the first 3 months. Contraindications are the same as for oral gestagens containing OK. The effectiveness of the method increases with increasing duration of use; Pearl index in the first 3 months about 4, then decreases to 1.
Norplant - depot-gestagen, enclosed in a capsule of biodegradable material. The capsule is implanted subcutaneously, for 1-2 years the progestogen is removed from it at a constant rate. The effectiveness of this type of contraception is high, the Pearl index is less than 1. Adverse effect: in the first months after the capsule is introduced, 12 to 14% of women have acyclic blood serous secretions from the genital tract, sometimes amenorrhea occurs.
Intrauterine contraception. There are more than 80 models of intrauterine contraceptive devices (IUDs). Distinguish between inert and medical Navy. Among the inert ones, the most widespread is the Lipps loop - a polyethylene device 2.5–3 cm long in the form of a double Latin letter S. Drug IUDs contain copper, gestagens (progestastert); more often, copper-bearing IUDs are used in the form of the letter T and the number 7 with copper wire wrapped around their branches. IUDs violate the implantation of a fertilized egg, which is associated with accelerated peristalsis of the fallopian tubes AND the resulting inferiority of the egg and the lack of endometrial-friendly conditions for implantation; copper has a bactericidal and spermicidal effect. The effectiveness of the IUD is quite high: the Pearl index using the Lipps loop is about 4, the copper-containing IUD is 1–2.
Contraindications for use IUDs are acute, subacute inflammatory diseases of the genital organs, chronic inflammation with frequent exacerbations, infectious and septic disease and fever of any etiology, cervical incompetence, benign and malignant tumors of the genital organs, polyps cervical canal, erythroplakia and leukoplakia neck uterus; polyposis and endometrial hyperplasia, genital tuberculosis, uterine malformations, intrauterine synechia, menstrual disorders by meno-or metrorrhagia, anemia, coagulation disorders of the blood, accompanied by increased bleeding.
The Navy is administered by a physician in compliance with the aseptic rules on the 5th day of the menstrual cycle, after induced abortion - immediately (or after another menstruation), after birth - 3 months later. The necessary conditions are a normal blood picture, I — II degree of vaginal purity.
The Navy is inserted in the position of a woman on a gynecological chair. Expose the cervix with vaginal mirrors and determine the length of the uterine cavity uterine probe. They select the appropriate sized IUD, using a special syringe-conductor, it is inserted through the cervical canal to the bottom of the uterus. Outlet threads of the contraceptive hanging from the cervical canal, cut at a distance of 2 to 3 cm from the external os of the uterus.
Within 7 - 10 days after the introduction of the Navy sexual life is prohibited. The doctor should examine the woman after 1 week after the introduction of the contraceptive, after the first menstruation, then after 3 months, the subsequent examinations are carried out 1 time in 6 months. The duration of the presence of the IUD in the uterus 3 - 5 years. A woman should independently check the location of the output of the IUD. If it ceases to feel them, it is necessary to consult a doctor, since in 9-16% of cases spontaneous expulsion of the contraceptive from the uterus can occur; its frequency is inversely proportional to the duration of the stay of the IUD in the uterus. After the introduction of the IUD, scant bleeding from the genital tract during the first intermenstrual period and more heavy periods are possible. These phenomena, as a rule, disappear on their own in 2–4 months.
The most common complications of intrauterine contraception are lower abdominal pain and uterine bleeding. In 1-2% of women have inflammatory diseases of the genital organs, while pathogens penetrate into the upper sections of the genital tract through the threads of the Navy. Complications are more common in women who have not given birth, especially in those with a history of abortion , so it is preferable to nominate an IUD for women who have given birth. When complications appear, the doctor removes the IUD with a string dangling from the cervical canal. When the threads break and the IUD is left or its parts in the uterine cavity, extraction is carried out under the control of hysteroscopy (in the absence of an inflammatory process in the genitals).
It must be borne in mind that when the IUD is located in the uterus, an ectopic pregnancy may occur, the interruption of which is also accompanied by succinic secretions from the genital tract and colicy pains in the lower abdomen. In order to clarify the diagnosis, a bimanual and ultrasound examination is necessary, and when confirming the diagnosis of ectopic pregnancy, urgent surgical intervention is performed.
Among the rare complications is uterine perforation . It can be partial (introduction of the IUD into the uterus muscle in the bottom or side walls) and complete (with part or all of the IUD moving into the abdominal cavity).
When the IUD is located in the uterine cavity, uterine pregnancy may occur, which in about 50% of cases ends in spontaneous abortion. Therefore, in such cases it is advisable to terminate the pregnancy.
For women who used the IUD, the generative function is not impaired. After IUD removal, pregnancy occurs in 30% of women after 1 month, in 60% within 3 months, and in 90% within 1 year.