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Contraception......

 

You Ought To Know

  • Contraceptives are the means of preventing an unwanted pregnancy.
  • There is no medical contraindication to use of any contraceptive method by adolescents or young people
  • Condoms are effective means of contraception as they provide dual protection against pregnancy and HIV transmission
  • Oral contraceptive pills are another contraceptive method popular with young people
  • Emergency contraception refers to any device or drug that is used as an emergency procedure to prevent pregnancy after unprotected sexual intercourse

 

What is contraception?

Why do young people need contraceptives?

What are the common barriers to Contraceptive use by young people?

What are the various contraceptive options available for young people?

Which are the contraceptives recommended for use in young people?

What are the Barrier methods?

What are the various hormonal contraceptives?

What is an Intrauterine Device (IUD)?

What is an Emergency Contraceptive (Morning-After Pill)?

 

What is contraception?

By definition, contraception stands for some deliberate preventive methods that prevent conception of women. These methods are called ‘contraceptives’ meaning ‘against conception’ or pregnancy. These include all temporary and permanent measures to prevent pregnancy resulting from coitus. Using contraceptives that are safe and reliable are a sign of responsibility and concern for oneself and one’s partner.

 

Why do young people need contraceptives?

·         Contraceptives like condoms reduce the risk of transmission of HIV (the virus that causes AIDS) from one person to other. It could be said that use of condom during sex is a must for two-way protection: first from unintended pregnancy and the other is the prevention of STIs including HIV/AIDS.

·         40 women every minute undergo unsafe abortion and 200 die each day (ICPD report, 2004). Termination of pregnancies could be risky to a young woman’s health. Using contraception to prevent unwanted pregnancies helps to reduce the toll of unsafe abortion.

·         Very young, adolescent women who become pregnant face serious health risks because their bodies may not be physically mature enough to handle the stress of pregnancy and childbirth. For them, use of contraception methods is a better and safe practice.

·         Contraceptive use also can help improve quality of life. Access to contraceptives allows women to decide if they want to have children or not and when to have them.

 

What are the common barriers to Contraceptive use by adolescents?

 

Generally speaking, adolescent are less likely than those over the age of 20 to use contraceptive methods. Reasons for this include lack of information, misinformation, and fear of side effects, along with geographic, social, cultural and economic barriers to access and use of contraceptive methods. Unmarried adolescents may find it difficult to access contraceptives, especially where strong cultural or religious beliefs condemn sexual activity among unmarried adolescents. Teenagers may be unwilling to disclose their sexual activity to parents or service providers. Also, the sporadic and unplanned nature of adolescent sexual activity can be an obstacle to consistent contraceptive use.

 

Discontinuation of contraceptives may be a particularly significant issue for adolescents, who have more limited access than adults to contraceptive services, and more unpredictable and irregular sexual encounters. Adolescents also often have inadequate or incorrect knowledge about the reproductive cycle and about effective use of contraceptives. They are more likely to abandon contraceptive use for reasons such as side effects and health concerns, desire for a more effective and convenient method, problems of access or their partner’s disapproval.

 

Sometimes married females seek contraceptive services in conservative, high-fertility societies, they encounter substantial, often explicit, provider resistance, as providers are sometimes influenced by cultural mores that prohibit contraceptive use among adolescents.

 

 Given that contraceptive methods like condoms are a male controlled method, a woman’s ability to negotiate for their use may be inhibited by gender –related power imbalances in sexual relationships. In many societies, the low status of women and the tolerance of male promiscuity are other related factors that hinder a woman’s ability to insist on condom use. In addition, lack of knowledge about STD/HIV transmission and the cultural norms regarding the discussion of sexual matters and the rights of the partners to initiate or refuse physical activity can further hamper the ability to protect them from infection.The inability to negotiate use of contraceptives is a major barrier for adolescent women, who are less likely to discuss the use of contraceptives with their partners.

 

What are the various contraceptive options available for young people?

 

When prescribed and used properly, all currently available contraceptives are safe and effective for healthy adolescents.

 

Healthy adolescents are medically eligible to use any of the methods that are currently available. Some concern does exist regarding the use of certain methods (for instance intrauterine devices), but this must be balanced with the advantages of avoiding pregnancy. However age, is an important social factor to take into account when considering irreversible methods, such as sterilization.

 

Which are the contraceptives recommended for use in adolescents?

 

Sexually active adolescents need to be aware of the importance of the protection against both pregnancy and STI/HIV. When used correctly and consistently, male condoms are the most effective method of preventing infections for those engaging in sexual intercourse, and can be highly effective in protecting against pregnancy as well. Another option for dual protection is to use condom in conjunction with the other methods, such as combined oral contraceptives or injectables.

 

While adolescents may choose to use any one of the methods available to them, some methods may be more appropriate for a variety of reasons. For example, using a method that does not require a daily regimen, as oral contraceptive pills do, may be more appropriate choice for an adolescent. For all women, side effects are a major reason for discontinuation of contraception, and this is true for adolescents as well.

 

Much of the advice regarding adolescents and contraceptive use has focused on unmarried adolescents, but many of those seeking family planning services are married.

Married adolescents may be particularly concerned about early return to fertility and may prefer to avoid injectable contraceptives. Young  married women may ,in some cases, feel a pressure to have children and , thus , may want to keep their contraceptive use private from their spouse or in –laws. They may also knowingly or unknowingly be in a relationship where they are at risk for STI/HIV.

 

For unmarried adolescents, non-penetrative sexual activity can be a option, even with those who have already commenced sexual intercourse. For those who desire to have sexual intercourse, condoms, or condoms in combination with another method for dual protection –are the best recommendation. For adolescents who are not in monogamous relationship, sexual activity may be sporadic and unplanned. In these circumstances, condoms are a good choice because they are widely available- easily and inexpensively –and can be used when needed. Adolescents, especially those in monogamous relationships may also desire to use other long acting methods. However the risk of contacting STI/HIV still remains and the option of using dual methods can be considered.

 

 

What are the Barrier Methods?

 

The aim of the various methods that come under this is to prevent the living sperm from meeting the ovum. A variety of barrier methods are available both for men and women. The available options include condoms, spermicidal (foam suppositories, tablets, creams, soluble films and jellies), diaphragms, cervical caps, and sponges. These methods act by mechanically or chemically preventing sperm from entering the uterus. The major benefit to users is the absence of long-term side effects and complications. In addition, the use of condoms, and to some extent other barrier methods, reduces the risk of STD transmission. Except for diaphragms and cervical caps, which require an initial examination and fitting by the provider, barrier methods can be obtained through non-medical suppliers.

 

 

Male condoms:

Condom is a thin rubber sheath, which is pulled over the erected penis. After ejaculation, semen stays in the condom and sperm does not get into the vagina. The size and thickness vary. Condoms are available in different colours, smooth and patterned and with different flavours. Usually condoms are lubricated, which makes it easier for the penis to penetrate into the vagina. Condom needs to be used during the entire intercourse because even the first drops appearing on the tip of the penis (pre-cum or the pre-seminal fluid) may contain a large amount of sperm.

 

 

Effectiveness:

 

When used correctly and consistently, the condom is an effective contraceptive. It is the best protection against sexually transmitted infections. This is why condom should always be used during temporary relationships even if some other contraceptives are used simultaneously.

 

Even one single intercourse without as condom could lead to the infection of sexually transmitted diseases. Although many sexually transmitted infections are symptomless in early stages, in the long run they may cause infertility.   

 

Female condoms

 

A female condom is a new method of contraception. It consists of a sheath made of thin, transparent, soft plastic. There are two rings in it, one at either end. At one end of the condom, there is a flexible plastic ring that is inserted into the vagina before sex so that, the penis goes inside the female condom. At the other end, a soft plastic ring or -triangle (often corresponding to the size of the pubic triangle) covers the vulva. The effectiveness is similar to the male condoms.

 

Advantages:

·         Use can be controlled by women

·         Designed to prevent both pregnancy and STDs.

·         No apparent side effects

·         No medical condition appear to limit its use

 

Disadvantages:

·         Expensive at this time and not available everywhere

·         Some women might feel embarrassing as it indicates that “OK, now I am ready.”

·         Sensitivity of the vulva, inner lips, clitoris and the genital wall, reduces significantly

 

To read more on condoms, click on ‘Safe sex’ in the Information Base.

 

Spermicides

Contraceptive foams, creams and jellies are all classified as spermicides, that is, sperm killers. They come in a tube or a can, along with a plastic applicator.

They contain a chemical called Nonoxylol-9. Spermicides are applied inside the vagina at least 10 minutes before the ejaculation takes place depending on the melting time. They kill sperm or make sperm unable to move toward the egg. Thus the spermicide is inserted much as a tampon is.

Spermicides consist of a spermicidal chemical in an inert base and they work in two ways: chemical and mechanical. The chemicals kill the sperms, while the inert base itself mechanically blocks the entrance to the cervix so that sperm cannot swim into it.

Spermicides are highly effective only when used with a diaphragm or a condom. It however does not protect against STIs / HIV/AIDS.

Important Note

Spermicides must be inserted at least 10 minutes before the intercourse and the second dose will be needed after one hour has passed.

 

What are the various hormonal contraceptive?

 

There are two kinds of contraceptive pills: combined pills containing progestin and estrogen and progestin-only pills, which are called mini pills.

 

a)     Combined oral contraceptive pills (COC). These pills contain combination of both female hormones i.e. Oestrogen and Progestogen

b)     Progestin only pill (Minipill) containing Progesterone only

 

The pill works generally by stopping ovulation (release of eggs from the ovaries). In natural menstrual cycle, the low levels of estrogens during and just after the menstrual period trigger the pituitary to produce Follicle Stimulating Hormone (FSH), which stimulates the process of ovulation.

The woman starts taking the pills on about day 5 of her cycle. Thus just when estrogens levels would normally be low, they are artificially made high. This level of estrogens inhibits FSH production, and the message to ovulate is never sent out.

 

It is an effective, safe and reversible contraceptive for women desiring to delay their first pregnancy or space the next child.

 

Each packet has 28 tablets; first 21 of which are white hormonal tablets and remaining 7 are coloured iron tablets for maintaining their continuity. The pill has to be taken daily and one must follow instructions for optimum effectiveness.

 

Hormonally, the action of the pill produces a condition much like pregnancy, when hormones levels are also high, preventing further ovulation and menstrual periods. Thus it is not too surprising that some of the side effects of the pill are similar to the symptoms of pregnancy.

 

Advantages:

  • Safe, effective and easily reversible
  • Decision lies with woman herself
  • Fertility returns soon after stopping pills
  • Reduces menstrual blood loss and thus minimizes the chances of anaemia
  • Relief from premenstrual symptoms (PMS) and menstrual pain
  • Regulates irregular menstrual cycle
  • Provides protection against pelvic infection
  • Reduces chances of developing cancer of uterus and ovary and protects tumours of breasts and ovarian cysts.

 

Disadvantages:

  • No protection from STI/HIV transmission
  • Not effective unless taken every day, which may be difficult to remember.
  • Not recommended for women who smoke

 

Possible Side effects: Nausea, vomiting, Breast tenderness, Headache, Spotting or bleeding between the periods, Slight Weight gain are some of the possible side effects but do not necessarily manifest in every user.

 

Implants

The implant system that is available is called Norplant containing a set of 6 small plastic capsules. Each capsule is about the size of a small matchstick.

The capsules are placed under the skin of a woman’s upper arm by surgical procedure. Norplant contains progestin-only hormone that is released steadily into the body very slowly from all 6 capsules in a very low dose.

A set of norplant implant prevents pregnancy at least for 5 years. It works in the similar way as the oral contraceptive pills.

 

Advantages:

  • Very effective (1 pregnancy in every 1000 women in the first year of use) and provide long term protection upto 5 years
  • Does not interfere with sexual intercourse
  •  Fertility returns immediately after removal of capsules

 

Disadvantages:

  • Changes in menstrual bleeding pattern, irregular bleeding, spotting, heavy bleeding, longer periods, or amenorrhea
  • Nausea
  • Acne or skin rash
  • Weight gain
  • Hair loss or more hair growth on the face
  • Do not protect against STIs/ HIV/AIDS

 

Important:

Most women do not have any of these side effects, and most of the side effects go away without treatment within the first year.

Implants must be performed only at the hospital or a Health Center by a qualified trained medical practitioner.

 

Injectable contraceptives

 

Injectable contraceptives are highly effective. Two kinds that have been approved for use in a large number of countries are DMPA(depo-medroxyprogesterone acetate) ,used in some 90 countries ,and NET-EN(norethisterone enanthate) ,approved in some 40 countries. They work in the same way as contraceptive pills by stopping ovulation and thickening cervical mucous plug making it difficult for sperm to pass through. One single dose helps prevent pregnancy for at least 3 months.

Both DMPA and NET-EN produce amenorrohea (cessation of menstrual periods)in many users. This effect is seen as a disadvantage by women who consider regular bleeding as a sign of good health and use menstruation as an indicator that they are not pregnant. Although a return to fertility following discontinuation can be delayed for 6-12 months, studies suggest that 60-78 % of women conceive within one year of last injection.

 

 

What is an Intrauterine Device (IUD)?

 

The intrauterine device is a small piece of plastic; it comes in various shapes. Metal or hormone may also be a part of the device.

The IUD is inserted by trained medical personnel and remains in place until the woman wants it removed. The silk thread hangs outside the cervix that helps in its removal if there is a need.

The leading hypothesis is that the IUD produces changes in the uterus and in this environment; sperm that reach the uterus are immobilized and cannot move into the fallopian tube. The egg may also move more swiftly through the fallopian tube, reducing the chances of fertilization.

 

Advantages:

 

  • Readily reversible – single decision leads effective long term prevention of pregnancy
  • Does not interfere with the sexual activities at all
  • Long lasting – mostly for about 10 years
  • No medicinal or hormonal side effects

 

Disadvantages

  • Menstrual change in the first 3 months – heavier and longer menstrual periods
  • Irregular bleeding and spotting between periods
  • Medical and pelvic examination is a must before insertion

 

The IUD cannot be used under various conditions which include anaemia, excessive or irregular menstrual bleeding, active genital tract infection (RTI), enlarged uterus, Previous history of ectopic pregnancy or caesarean section and medical disorders e.g. diabetes, heart disease etc.

Note: IUD must be inserted only at the hospital or a Health Centre by a qualified trained gynaecologist.

 

What are the Traditional or Natural Methods of Contraception?

 

There are some methods of contraception that are called natural methods of contraception. The effectiveness of all methods depends on couples motivation to prevent pregnancy and the ability to interpret symptoms of ovulation. In general, older and more experienced users have a low failure rate.

 

Abstinence: If one abstains from sex or avoids sex, that is the safest contraceptive possible. After all, the best way to avoid an effect is to avoid its cause. But it may not be a feasible option for many adolescents and young people.

 

Sex without penetrative intercourse: One can express love and caring for one’s partner through acts other than vaginal intercourse. These may indulge in hugging, kissing, cuddling, light or heavy petting or mutual masturbation. From the point of view of contraception, this is as safe as abstinence.

The danger, however, lies in the fact that one may find it difficult to control themselves in an intimate situation and actually end up having penetrative sex.

 

Withdrawal method: Withdrawal is probably the most ancient form of birth control. It is still widely used throughout the world. During sexual intercourse, when the penis is withdrawn just before ejaculation and the semen is discharged outside the vagina, fertilisation cannot occur. This method is known as “coitus interrupts” or pulling out”.

 

  • This method calls for a great deal of self-control and mental strength from the male partner.
  •  It is a risky method to use because even the pre-cum or the pre seminal fluid contains sperms, which can lead to pregnancy or transmission of HIV.
  • Does not protect against sexually transmitted infections or HIV
  • Over long periods of time, withdrawal may contribute to sexual dysfunctions in the man, such as premature ejaculation, and also sexual dysfunction in the woman.

 

Fertility Awareness-Based Methods (FAM)

 

Rhythm or Calendar method

Before following this method, the woman records the number of days in each menstrual cycle for at least 6 months. The first day of the menstrual bleeding is always counted as day 1.
The woman subtracts 18 from her shortest recorded cycle. This tells her the estimated first day of her fertile time. Then she subtracts 11 days from her longest recorded cycle. This tells her the last day of her fertile time. The couple avoids sex or use a barrier method or contraception during the fertile period. The rest of the days are considered safe. However this method is not suitable for a woman with irregular menstrual cycles.

 

Cervical Mucous Method:

This method is based on the fact that the cervical mucus becomes very resilient and transparent just before ovulation making it easily penetrable for sperms. This method uses cervical secretions to identify the beginning and end of the fertile time. However the method is not very reliable for young users who cannot determine the consistency of the cervical secretions.

 

Basal Body Temperature (BBT) Method:

The BBT method uses body temperature to regulate fertility.

The woman must take her temperature in the same way, orally, rectally or vaginally, at the same time each morning before she gets out of bed.

She must know how to read a thermometer and must record her temperature on a special graph. About midway during the menstrual cycle, at the time of ovulation, a woman’s temperature rises 0.2° to 0.5°C (0.4 to 1.0°F).

The couple should avoid sex or use contraception from the first day of menstruation until her temperature has risen above her regular temperature and stayed up for three full days. This means that ovulation has occurred and passed.

 

What is an Emergency Contraceptive (Morning After Pill)?

 

Emergency contraception refers to any device or drug that is used as an emergency procedure to prevent pregnancy after unprotected sexual intercourse. Synonymous terms for EC include "the morning-after pill," post coital contraception, interception, postovulatory contraception, "visiting pill," and "vacation pill."

 

Emergency contraception is indicated for the prevention of pregnancy in women after a known or possible contraceptive failure or unprotected sexual intercourse and for victims of sexual assault. It is not recommended as a form of routine contraception. Although EC reduces the risk of pregnancy, it is much less effective than the regular use of standard contraception.

They are thought to act primarily by inhibiting or disrupting ovulation. In addition, they may act by interfering with tubal transport of the ova and/or sperm, thereby inhibiting fertilization, or by inhibiting implantation through alteration of the endometrium.

 

Emergency contraception (EC) should be undertaken within 72 hours of unprotected sexual intercourse; the sooner it is started, the more effective it will be in preventing pregnancy (recent data indicate that EC is effective <120 hours). If emesis occurs within 1 hour after a dose, the dose should be repeated.

 

The use of Emergency Contraception is generally not associated with any serious adverse effects, even though the doses used are higher than those used for routine contraception. Pregnancy is a contraindication to EC because EC is ineffective if a woman is pregnant. There is no significant increase of teratogenic (leading to malformations or deformities) risk on fetal development associated with the long-term use of oral contraceptives administered before pregnancy or taken inadvertently during early pregnancy. Although EC is not intended for routine contraceptive use, its use after failed contraception could minimize the number of unanticipated pregnancies, preventing the physical and emotional burden of an unwanted pregnancy, in addition to reducing health care costs.

 

Common adverse effects of EC include nausea, emesis, headache, irregular bleeding, breast tenderness, and abdominal cramping. An antiemetic can be prescribed to prevent nausea and emesis.

 

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