CONTRACEPTION

CONTRACEPTION - protection from conception. It is used as a means of family planning, and is also indicated in cases where the prognosis of a possible pregnancy is unfavorable for a woman or a future child.

Protection from unwanted pregnancy, taking into account the age of the woman, the interval between births, the state of health of women and family members, helps to reduce gynecological morbidity and perinatal mortality. Therefore, contraception can be considered as an effective method of prevention, allowing to maintain the health of women.

There are the following methods of contraception, preventing sperm from fertilizing the egg or implanting 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 common before the introduction of hormonal and intrauterine contraception. The means by which barrier, chemical, hormonal and intrauterine methods of contraception are implemented are called contraceptive methods. The effectiveness of any of the methods of contraception is estimated using the Perle index, which is equal to the number of pregnancies that occurred in a group of 100 women who use a certain method of contraception for 12 months.

Barrier (mechanical) methods of contraception are based on the use of drugs that create a mechanical obstacle to sperm penetration into the cervical canal - condoms, vaginal diaphragm and cervical cap. Contraceptive effectiveness of the condom is relatively low, the Pearl index is 14-18. Using a condom helps prevent infection with sexually transmitted diseases, including HIV.

Spermicidal (chemical) methods of contraception are based on the use of drugs that are detrimental to sperm. This gramicidinovaya paste, galaskorbin (vaginal pills). Spermicidal paste (5 - 6 g) is introduced into the vagina for 5 - 10 minutes before sexual intercourse, tablets - for 10-15 minutes.

Chemical contraceptives can be used with a shallow back of the vaginal vault and a cervical deflection posteriorly. With a tendency to allergic reactions, they are not recommended. The Pearl Index is 20-25. For the purpose of contraception, vaginal douches can also be used with solutions possessing spermicidal properties, for example, 2.5% acetic acid solution, 0.01% potassium permanganate solution (1 teaspoon 2% potassium permanganate solution per 1 liter of water), 20% chloride solution Sodium, a solution of lemon juice (juice of one lemon per 0.5 liters of water). The Pearl Index is 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 Perl index is 24. Somewhat more efficient 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 the intercourse occurs only after ovulation and 12 if before and after ovulation) . Symptoms that testify to ovulation are determined by the woman herself; They include an increase in the number of cervical mucus, an increase in the rectal temperature above 37 ° C. The rhythmic method can not be used with an irregular menstrual cycle.

Interrupted sexual intercourse is a method of contraception, based on the termination of sexual intercourse before the beginning of ejaculation. Essential shortcomings of the method are its low efficiency (Pearl index 18-20), often developing with prolonged use of the method of neurosis and impotence in men, pelvic pain in women.

Hormonal contraception is almost 100% effective. Women taking hormonal contraceptives reliably established a decrease in the incidence of cancer of the endometrium, ovaries and mammary glands. After the termination of hormonal contraception, the gene function is restored within 3 to 6 months.

There are tableted (oral), injected intramuscularly and implantable under the skin hormonal contraceptives. Of these, the most common oral contraceptives (OC).

According to the composition, combined estrogen-gestagenic and gestagen-containing hormonal contraceptives are isolated. Combined estrogen-progestogens are OK. One-, two- and three-phase combined estrogen-gestagenic OK are known. Single-phase OCs are tablets with a constant content of estrogens and progestins. They include non-vellon , 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 (ригевидон) 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 every day for one tablet at the same time of day. It is unacceptable to interrupt the reception of tablets, in extreme cases, the next day after the break should take two tablets. The duration of continuous intake of non-vildone, bisekurin, ovulin, and rigevidone is 2 to 5 years with good tolerability. During this time, the obstetrician-gynecologist should examine the women 1 time in 3-6 months. When bloody discharge from the genital tract against the background of taking these drugs should be on 2 - 3 days to increase the dose to 2 tablets a day. The taking of pills is stopped when there is an acute headache, chest pain, legs, and also for 1 month before the forthcoming surgical intervention.

The efficacy of single-phase OK is very high, the Pearl index is less than 1. In addition, they contribute to the regulation of the menstrual cycle, the reduction of blood loss during menstruation, the disappearance of pain and other painful symptoms associated with menstruation, have a pronounced therapeutic effect in endometriosis of any site, fibrocystic mastopathy , Hyperplasia and polyposis of the endometrium, follicular cysts of the ovaries, inflammatory diseases, especially recurrent, internal genital organs.

If single-phase OK is used, complications and adverse reactions are possible. The most dangerous thromboembolism (its frequency is 1: 100 000) and other diseases associated with hypercoagulability (phlebitis, thrombophlebitis). The development of these complications is promoted by such factors as obesity , diabetes , smoking , hypertension , lipid metabolism disorders and severe forms of toxicosis of pregnant women in the anamnesis.

Contraindications to the use of these drugs are age over 40 years (35 years for women smokers or for obesity III - IV degree), arterial hypertension , acute liver or kidney disease, jaundice during pregnancy, varicose veins or postthrombotic syndrome, any tumor Localization (or suspicion of it), severe toxicosis of pregnant women in the anamnesis .

Two-phase OCs include two types of tablets intended for reception in the first and second phases of the menstrual cycle, respectively; The content of estrogens in them is the same, but in tablets taken in the second phase of the menstrual cycle, there are more progestogens.

Three-phase OK (for example, trisiston, trikwilar) contain estrogens and gestagens in various combinations. In tablets of the first type, the content of estrogens and gestagens is the smallest, in the tablets of the second type the dose of estrogens and gestagens increases, in tablets of the third type the estrogen content decreases, and the dose of gestagens rises. The content of estrogens and gestagens 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: the first 6 days use tablets of the first type, then 6 days - of the second type, in the next 9 days - of the third type. Three-phase administration of sex steroids Allows the same change in the blood levels of estrogens and gestagens, as in the normal menstrual cycle.

The effectiveness of three-phase OK is very high, the Pearl index is less than 1. These drugs do not cause an increase in blood pressure, changes in the system of hemostasis, violations of lipid and carbohydrate metabolism. In addition, these drugs have a therapeutic effect in mastopathy, some forms of premenstrual syndrome, anovulatory menstrual cycles.

The contraceptive effect of combined estrogen-progestational OK is inhibition of ovulation due to suppression of ovulatory release of gonadotropins in the anterior pituitary gland, failure of implantation as a result of inhibition of secretory changes in the endometrium, and impairment of cervical mucus permeability for spermatozoa in the cervical canal.

Gestagen-containing contraceptives include so-called mini-pili containing microdoses of gestagens, postcoital OK and long-acting agents.

Mini-pills (for example, continuum, femulin) are prescribed continuously, daily from the first day of the menstrual cycle for 6 to 12 months. Their contraceptive effect is based on inhibition of the contractile activity of the fallopian tubes, increased mucus viscosity in the cervical canal, disruption of cyclic processes in the endometrium. Contrastative efficacy is slightly lower than in estrogen-containing OK; The Perl index is 1.5 - 1. Mini-pills do not cause metabolic changes and hypertension, virtually do not interfere with the blood coagulation system. A side effect limiting the use of these drugs is menstrual cycle disorder - prolonged spotting, which is observed in 12-14% of women. The use of these drugs is contraindicated in acute and chronic liver diseases, including jaundice, suffered during pregnancy.

Postcoital OKs are recommended for women who live irregularly (rare sexual intercourse). They include postinor, containing 0.75 mg of progestogen. One tablet of the drug is taken within 1 hour after sexual intercourse. Contraceptive action is based on preventing the 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. Efficacy of postcoital OK, complications and contraindications are the same as when using mini-pills.

Mediakroprogesterone acetate and norplant are referred to long-acting gestagen containing contraceptives . Medroxyprogesterone acetate, containing 150 mg of progestogen, is administered intramuscularly. The first injection is carried out on the 5th day of the menstrual cycle, the subsequent injection every 90 days. The contraceptive effect of this drug is associated with a decrease in permeability (increased viscosity) of cervical mucus for spermatozoa, 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 suppository allocation, especially in the first 3 months. Contraindications are the same as for oral gestagen-containing OK. The effectiveness of the method increases as the period of application increases; Pearl index in the first 3 months about 4, then decreases to 1.

Norplant - depot-gestagen, encapsulated in a biodegradable material. The capsule is implanted subcutaneously, within a period of 1-2 years, gestagen is released from it at a constant rate. The effectiveness of this type of contraception is high, the Pearl index is less than 1. Side effect: in the first months after capsule administration, in 12-14% of women acyclical sutures from the genital tract are noted, sometimes amenorrhea occurs.

Intrauterine device contraception. There are more than 80 models of intra-uterine contraceptives (IUDs). There are inert and medicamental IUDs. Among the most common is Lips's loop - a polyethylene device 2.5-3 cm long in the form of a double Latin letter S. Medical IUDs contain copper, gestagens (progestasert); More often use copper-bearing IUDs in the form of the letter T and the number 7 with a copper wire wrapped around their branches. IUDs impair the implantation of a fertilized egg, which is associated with accelerated peristalsis of the fallopian tubes and the inferiority of the ovule and the lack of conditions favorable for implantation in the endometrium; Copper has a bactericidal and spermicidal effect. The efficiency of the IUD is quite high: the Pearl index with the Lips loop is about 4, the copper-containing IUD is 1-2.

Contraindications for the use of the IUS are acute, subacute inflammatory diseases of the genital organs, chronic inflammatory processes with frequent exacerbations, infectious-septic diseases and fever of any etiology, ischemic-cervical insufficiency, benign and malignant tumors of the genital organs, cervical canal polyps, erythroplasty and cervical leukoplakia The uterus; Polyposis and hyperplasia of the endometrium, tuberculosis of the genitals, malformations of the uterus, intrauterine synechia, menstrual irregularities such as menopause or metrorrhagia, anemia, disorders of the blood coagulation system, accompanied by increased bleeding.

The IUD is administered by a doctor following the rules of asepsis on the 5th day of the menstrual cycle, after an induced abortion - immediately (or after another menstruation), after birth - after 3 months. Necessary conditions are a normal picture of blood, I-II degree of purity of the vagina.

The IUD is administered in the position of a woman on a gynecological chair. The cervix is ​​exposed with the help of vaginal mirrors and the length of the uterine cavity is determined by the uterine probe. Select the appropriate size of the IUD, using a special syringe-conductor it is introduced through the neck canal to the bottom of the uterine cavity. The lead threads of the contraceptive, hanging from the cervical canal, are cut at a distance of 2 - 3 cm from the outer throat of the uterus.

Within 7 to 10 days after the introduction of the IUD, sexual intercourse is prohibited. The doctor should examine the woman 1 week after the introduction of the contraceptive, after the first menstruation, then after 3 months, the subsequent examinations are carried out once every 6 months. The duration of the IUD in the uterine cavity is 3 to 5 years. The woman should independently check the location of the output strands of the IUD. If she ceases to feel them, you need to see a doctor, as in 9-16% of cases, spontaneous expulsion of the contraceptive from the uterine cavity may occur; Its frequency is inversely proportional to the duration of the IUS in the uterus. After the introduction of the IUD, scant bloody discharge from the genital tract during the first intermenstrual interval and more abundant menstruation are possible. These phenomena, as a rule, disappear on their own in 2-4 months.

The most frequent complications of intrauterine contraception are abdominal pain and uterine bleeding. In 1-2% of women there are inflammatory diseases of the genital organs, while the pathogens penetrate into the upper sections of the genital tract along the threads of the IUD. Complications are more common in nulliparous women, especially those who have a history of abortion , so the IUD is preferable to appoint women giving birth. At occurrence of complications the doctor extracts the IUD for a string hanging from the cervical canal. When the threads break and leave the IUS or a part of it in the uterine cavity, the extraction is carried out under the control of hysteroscopy (in the absence of an inflammatory process in the genital organs).

It should be borne in mind that when the IUD is in the uterine cavity, there may be an ectopic pregnancy, the interruption of which is also accompanied by sucritic discharge from the genital tract and cramping pains in the lower abdomen. To clarify the diagnosis, a bimanual and ultrasound examination is necessary, with the confirmation of the diagnosis of an ectopic pregnancy, urgent surgical intervention is performed.

Among the rare complications is the perforation of the uterus. It can be partial (insertion of the IUD into the uterine muscle in the region of the bottom or side walls) and complete (with the movement of part or all of the IUD into the abdominal cavity).

When the IUD is in the uterine cavity, a uterine pregnancy can occur, which in about 50% of cases ends in a spontaneous abortion. Therefore, in such cases, it is advisable to terminate the pregnancy.

In women who used the IUD, the generative function is not impaired. After the extraction of the IUD, pregnancy occurs in 30% of women after 1 month, in 60% for 3 months and in 90% for 1 year.