CONTRACEPTION

The traditional or natural methods of contraception involve all measures to prevent pregnancy due to sexual act other than the use of any device, barrier, medication or surgery. It involves taking note of the woman’s fertile periods; using the menstrual calendar, some symptoms, signs and avoiding sex during the fertile period.

Naturally, a woman’s sexual receptiveness increases during her fertile period so, natural methods of contraception require a great deal of discipline. This increases the failure rate; the number of women per 100 that will conceive while on a particular method of contraception in one year.

The focus here will be on the natural or traditional methods of contraception. To catch up on previous publications on the introduction to this series and for oral hormonal contraception read here.

LACTATIONAL AMENORRHOEA METHOD OF NATURAL CONTRACEPTION

Amenorrhoea is the cessation of menses for a period of at least 6months. Lactation is the secretion of milk from the breasts. Some women after delivery will not see their menses for about 6 to 12 months while actively breastfeeding their babies. During breastfeeding, there is an upsurge of the hormone prolactin which suppresses the hypothalamic hormone (gonadotrophin releasing hormone) and the pituitary hormones (follicle stimulating and luteinizing hormones). This results in suppression of ovulation and cessation of menses.

This physiologic process is used as a form of natural contraception. For this to be effective, breastfeeding has to be exclusive. This method should not be used for more than 6months. It is worthy to note that a woman can conceive within three to four weeks of delivery even if her menses has not returned. Its failure rate is 2 per 100 women use per year with typical use within the first 6months.

THE WITHDRAWAL METHOD OF NATURAL CONTRACEPTION

The withdrawal method also called coitus interruptus involves the removal of the penis from the vaginal before ejaculation. Both partners here will require self-control; the male may not be able to withdraw before ejaculating or the female may interfere preventing successful withdrawal. This result in high failure rate of this method. Also, before ejaculation occurs, the pre-ejaculatory fluid may contain some sperm cell. In couples using only this method with high success, one may wonder whether the withdrawal is very efficient or it is the sperm that is inefficient. Its failure rate is about 22 pregnancies per 100 women use per year with typical use.

DOUCHIING AFTER SEX

The use of a combination of water, vinegar and certain substances to wash the vaginal after sex has been practiced traditionally for contraception. The aim here is to wash out the sperms before they get the chance to swim up. This method is highly ineffective because it takes few minutes for the sperm cells to get into the cervix where the douching cannot reach.

THE PERIODIC ABSTINENCE METHOD

This method takes into consideration the fertile and non-fertile periods of a woman using symptoms, signs and knowledge of the menstrual cycle. During the fertile period, sex is avoided, this is how contraception is achieve using this method. Periodic abstinence in typical use is associated with a failure rate of 25 pregnancies per 100 women use per year.

The calendar method: is a method of periodic abstinence where a woman’s menstrual cycle is studied to know her fertile period. The time of ovulation to onset of the next menses is constant which is 14 days. This method is preferable for women with a regular 28days cycle. The sperm survives in the female genital tract for about 2 to 3days after ejaculation, while the egg survives for about 24 to 48hrs after release from the ovary. The use of this knowledge and the estimate of a probable day of ovulation, sex can be avoided as a means of contraception.

However, the above may not really apply to women with menstrual cycle shorter or longer than 28dys. For this group of women, their fertile periods can be calculated from their cycle length calendar. A calendar of at least 6month is preferred, where 20 is subtracted from the shortest cycle and 11 from the longest cycle to get a range of days for the fertile period.

For instance, a woman whose shortest cycle in a 6 or 12 calendar month is 26days and her longest cycle is 30days, her fertile period is days 6 to 19 of her cycle. During this period, sex should be avoided when using the calendar method of contraception.

The basal body temperature method: the hormone progesterone has thermogenic effect, that is, it can cause a rise in body temperature. This can be used to monitor ovulation for contraception purpose. The body temperature drops 24 to 36hrs after ovulation and suddenly raises again by about 0.3 to 0.4⁰C (0.5 to 0.7⁰F) and remains so for the rest of the cycle. The fertile period ends on the 3^rd day of the rise in body temperature.

To use this method, a vaginal or rectal thermometer is used daily to measure the body temperature before the woman gets up from her bed to do any activity. She has to be sure that the rise in temperature is not due to any infection that may give a wrong interpretation.

The basal body temperature readings can be combined with the calendar method for a more accurate prediction of ovulation. This is associated with a failure rate of 5 pregnancies per 100 women use per year.

The cervical mucus method: this is also called the billings method. The cervical mucus has different consistency at different time of the menstrual cycle due to the influence of hormones. Shortly before and just after ovulation, the cervical mucus becomes thin, clear, slippery and stretchy (spinnbarkeit). This is the fertile period and sex should be avoided for contraception. The hormone progesterone released after ovulation makes cervical mucus thick and opaque, this hinders sperm penetration. Sex is allowed 4days after the maximum thickness of the mucus till menstruation.

The progesterone component of oral hormonal contraception works using this mechanism. The drawback of this method is the challenge in assessing the cervical mucus in the presence of infection.

The sympto-thermal method: combines symptoms and signs of ovulation with measurement of basal body temperature to predict ovulation. The cervical mucus assessment is used along with other symptoms such as nausea, bloating and vulvar swelling to predict ovulation.

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Oral hormonal contraception is the use of oral medication containing one or two hormones for the purpose of pregnancy prevention. These hormones are basically the two female hormones oestrogen and progesterone. Oral hormonal contraceptive medication containing the two hormones is called combined oral contraceptive while that containing only progesterone is called progesterone only contraceptive pill. The focus here is going to be on the combined and progesterone only oral hormonal pills

 For the introductory part of the series on contraception, please read here to catch up with the discussion.

HOW ORAL HORMONAL CONTRACEPTIVE MEDICATION WORKS

Oral hormonal contraceptive medication works by preventing ovulation (release of egg from the ovary), thickening the cervical mucus and thins the endometrium making it hostile for implantation. These medications mimic the natural female hormones; oestrogen and progesterone. When they are taken, they get into the blood stream and make the brain to feel like there is enough of the female hormones. This sends signals to stop further production by stopping the release of another set of hormones from the brain called the follicle stimulating hormone and luteinizing hormone. They are responsible for the maturation of the egg, production of oestrogen and release of the egg.

WHO IS ELIGIBLE FOR ORAL HORMONAL CONTRACEPTION?

Women of reproductive age who are in need of contraception can use either the progesterone only or combined pill. The use of combined oral pill is not recommended in the following conditions;

• Current or previous history of Venous thromboembolism
• Undergoing major surgery that may require one to be bedridden for a long time
• Breast cancer
• Liver cancer
• Acute hepatitis
• Hypertension
• Migraine with aura
• Women ≥35years who smoke
• Certain medication for convulsion
• Women with ischemic heart disease
• Women with stroke or who have multiple risk factors for stroke
• Less than 6weeks after delivery and breastfeeding

The use of progesterone only pill is not recommended in the following condition;

• Breast cancer
• Liver cancer
• Acute venous thromboembolism
• Some medication for convulsion

ORAL CONTRACEPTIVES AND INTERACTION WITH OTHER MEDICATIONS

Some medication interact with oral hormonal contraceptive and decrease the efficacy of oral contraceptive pill. Speak with your doctor if you are on antibiotic for tuberculosis (rifampicin and rifabutin), seizure medication (carbamazepine, phenobarbital, phenytoin and topiramate) and human immune deficiency virus(HIV) medication.

EXAMINATION AND TEST DONE BEFORE COMMENCING THE PILLS

Pregnancy test is done to ensure the woman is not pregnant. Blood pressure check, weight and height to calculate the body mass index. The body mass index will be used to monitor the use of oral hormonal pills. Additional test may be needed for women with other medical conditions.

WHEN TO START TAKING ORAL CONTRACEPTIVE PILLS

The initiation of oral contraceptive pills can be at any time of the menstrual cycle. It is best started within the first five days of the onset of menses. After that, additional contraception should be used (condom) or avoid sex for the next seven days of commencement.

HOW SHOULD ORAL HORMONAL CONTRACEPTIVES BE TAKEN?

It is best you take your pill at a specific time of the day for effectiveness. This will help avoid lateness or missed pill as this will affect the effectiveness and increase the failure rate. The failure rate with perfect use of these pills (combined and progesterone only) is about 3 in 1000 women who used the method in one year. This means in one year, if 1000 women use this method the way it is supposed to be used, only three will be pregnant while on it.

For progesterone only pill, one pill should be taken daily preferably at the same time. After completion of a pack, the next pack should be started the next day at the same time. For combined oral pill, Start taking the pill from where the pack was marked start, take one daily till you complete the pack (28th pill). The last seven pills are inactive and you should see your menses while taking it. Start another pack the next day after completing the white inactive pills even if still menstruating.

WHAT TO DO WHEN YOU FORGET TO TAKE YOUR CONTRACEPTIVE PILL

A dose is considered missed if more than three hours for traditional progesterone,12hours for desogestrel pill and 24hours for combined oral pill have elapsed from the time the next dose should be taken. It is considered late if the time has elapsed from when the next dose should be taken but still within 3 or 12hours for progesterone only pill and within 24hours for combine oral pill.

So, take the late pill as soon as you remember and continue as scheduled even if it means taking two pills on the same day. No additional contraceptive protection is needed. Additional contraception should be considered if this occurs earlier in the cycle, or in the last week of the previous cycle if sex is contemplated or emergency contraception should be used if sexual intercourse occurred within the previous five days.

More so, for missed pill, even when two or more consecutive pills have been missed, take the most recent missed pill as soon as you remember and discard any other missed pills. Continue taking the pills as scheduled even if it means taking two pills on the same day. Avoid sexual intercourse or use backup contraception (condom) for the next seven consecutive days. if sexual intercourse had occurred within the previous 5days, emergency contraception is indicated.

If pills were missed in the last week (day 15 to 21) while on the 28days pill, continue taking the pill omitting the hormone free interval (white pills) after which you continue with a new pack the next day. If this is not feasible, use backup contraception or avoid sex until resumption of the new pack for seven consecutive days.

SIDE EFFECTS OF ORAL HORMONAL CONTRACEPTIVES

Nausea

Vomiting

Diarrhoea

Abnormal menstrual bleeding

mood changes

headache and migraine

breast tenderness and enlargement

Weight gain

HOW ORAL CONTRACEPTIVES ARE ELIMINATED FROM THE BODY?

These pills when taken orally are absorbed into the blood stream. They are eliminated from the body through faeces and urine after been broken down in the liver

NON CONTRACEPTIVE BENEFITS OF ORAL HORMONAL CONTRACEPTION

Combined oral pills can be used in women having heavy or painful menses and premenstrual syndrome. It also helps to regularize the menses in women with polycystic ovarian syndrome and reduce the symptoms of patient with endometriosis.

WHAT ORAL CONTRACEPTIVE PILL IS NOT USE FOR?

Oral contraceptive pill is not used as an abortifacient (to cause abortion) and it does not protect from sexually transmitted infection. Use additional barrier method if you are not sexually exclusive with your partner.

Is contraception illegal as abortion? Then, why do some women not use any form of pregnancy prevention method? What remain a fact here is, you cannot eat your cake and have it; if you must have sex, keep it in mind that pregnancy might be inevitable without any form of contraception. I can tell you categorically that, there is no country in the world where contraception is illegal. Even if you know one country, I will still convince you that it is not entirely true. I will let you know why it is not entirely true in this post. Contraception maybe accepted partially; for some, it is for cultural or religious reasons, while for others it might be personal or are compelled by the laws of their region.

Even if there is a country where contraception is illegal, I am certain the legality will lie with the method of contraception use. The law will certainly not follow you to your home or bedroom to know if you practice any natural methods of contraception. By this, I am not in any way advocating for natural methods because of their high failure rates though, no contraception is 100% effective. Moreover, the failure rate for the most effective pregnancy prevention method is < 5 in 1000 women who use the method per year.

WHY THE QUESTIONS?

So, why the query whether contraception is illegal as abortion? And why do some women not use any form of contraception?

In the course of my training as a resident, I was fortunate to be directly involved in the management of four women who were not fortunate. They all have a lot in common; they were not on any effective contraception, three of them were married and one single but sexually active, they were pregnant and procured an illegal abortion, their womb or womb with one or both ovaries decayed inside them, they all had operation with removal of the womb or womb with one or both ovaries, ended up in the intensive care unit. Three of these women died. This would not have happened if they had access to safe abortion and after abortion care.

In Nigeria, there are laws that prescribe punishment for procuring or performing abortion, except the pregnancy threatens to take the life of the mother. However, there are reasons that affect the uptake of contraception as outlined below. The danger of having an unsafe abortion is so scary for any sexually active female not to consider any form of contraception, even the most ineffective one.

WHAT IS CONTRACEPTION?

Whether you like to hear it or not. You are most likely using a contraceptive method even without your knowledge. At times, I often get responses like, ’’I do not use any contraception’’ during consultation at the gynaecology or post-natal clinic when I ask the patient if they use contraception. What then is contraception? Contraception involves all the measures, whether temporary or permanent, that are designed to prevent pregnancy due to sexual act.  

If you know what contraception really is, then you will realize you are already using one. If you never knew you were using any method of contraception until you read this post, then you should know the method you are using is most likely not very effective. Unless what you are doing or taking is not for the purpose of pregnancy prevention then it is not contraception. Yes, I know, you have been getting results and your children are all spaced at least 3years. Remember I said, ‘not very effective’, I did not say it does not work. It means it has a higher chance to fail than other methods.

FORMS OF CONTRACEPTION

There are different forms of contraception and this are broadly classified as natural and artificial methods.

The natural methods consist of measures not involving the use of any device, barrier or medication. It involves taking note of the woman’s fertile periods; using the menstrual calendar, some symptoms and signs. Then, avoiding sex during the fertile period. Naturally, a woman’s sexual receptiveness increases during her fertile period, hormones don’t lie.

The artificial methods involve the use of barriers, devices, medication and surgical occlusion of the fallopian tubes (bilateral tubal ligation) or the vas deferens in males (vasectomy).  

POSSIBLE REASONS FOR POOR CONTRACEPTION UPTAKE

Like I mentioned earlier, the uptake of contraception is influence by both personal, cultural, religious and scientific reasons. The number of children a man has used to be a symbol of his greatness and wealth in Africa. These children serve as his main labour force in his farms. This reason is fast becoming an idea you can only find in the museum. However, it might baffle you to know that a certain traditional title come with the number of children a woman has in some states in Nigeria. From the religious point of view by the two most dominant religions in the world, sex seems to be an act purely for procreation hence, nothing should interfere with the sperm getting into the female reproductive tract.

Therefore, certain contraceptive methods are preached against; like the natural withdrawal method, the hormonal and non-hormonal methods of contraception might not be accepted, depending on the religious sect or denomination. Also, the debate by some of the religious denomination is backed by some scientific publications on the effect of contraceptives on aquatic life. The life of animals that live in water is affected by a component of the contraceptive pills that is not completely broken down by the woman’s body when she takes the combine pill. This can get into bodies of water through the disposal of non-treated sewage into the water body.

Maybe, there will be no fish left in our water bodies in the future if we keep emptying our untreated sewage into our rivers or streams. Just imagine a world without a fish as a meal or part of a meal (that’s on a lighter note). Some individuals may not be aware of some of the most effective hormonal methods of contraception. Those who are aware and may want to use them, may not be able to afford them. Also, some women believe that using hormonal contraception will interfere with their future fertility. Therefore, they only subscribe to its use after they have completed their family size.

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Bilateral tubal ligation (BTL) is a permanent surgical contraception. It is also called voluntary sterilization. This is surgical procedure whereby the reproductive function of an individual male or female is purposefully and permanently destroyed.

Female permanent contraception is called female sterilization or bilateral tubal ligation. This is defined as the occlusion or division of the fallopian tubes to prevent egg and sperm passage and subsequent fertilization. Female permanent contraception is the world’s most common method of family planning though, men are increasingly taking up vasectomy.

INDICATIONS FOR BILATERAL TUBAL LIGATION

Factors that are associated with increased use of permanent contraception include;

• Increasing age.
• Family planning purposes: This is the principal indication in most of the developing countries.
• Socioeconomic; an individual is adapted to accept the method after having the desired number of children.
• Therapeutic: Medical diseases such as heart disease, diabetes, sickle cell disease, chronic renal disease and hypertension are likely to worsen if repeated pregnancies occur and hence sterilization might be offered as an option.
• Prophylactically: The Society of Gynecologic oncology currently recommends consideration of opportunistic bilateral salpingectomy (excision of the fallopian tubes) as a preventive measure against serous ovarian and peritoneal cancers among women who are at average risk of ovarian cancer and are undergoing other pelvic surgery.

CONTRA-INDICATION TO BILATERAL TUBAL LIGATION

Patient ambivalence regarding sterilization is an absolute contraindication. Even though surgically reversing the tubal occlusion at a later date or becoming pregnant through in vitro fertilization(IVF) is technically feasible.

WHAT TO EXPECT AT CONSULTATION WITH YOUR DOCTOR?

During counselling when permanent contraception is considered, this will involve a shared decision making with your doctor. Counselling regarding alternative methods of contraception, their risks and benefits to permanent contraception will be discussed. The risks and benefits of the procedure will also be discussed and your expectations and concerns established and addressed.

Bilateral tubal ligation does not interfere with menses; as you will continue to see your menses and it does not affect your sexual life. Your doctor will tell you that it’s one of the best method of contraception but it can also fail just like other methods, but it is associated with very low failure rate; <1 in 100 women who will have it per year. Your doctor will let you know that bilateral tubal ligation is also associated with regret and the risk factors for regret will be assessed and discussed.

RISK FACTORS FOR REGRET AFTER BILATERAL TUBAL LIGATION

 It has been reported that 7 in 100 women that had tubal ligation had regrets by the 5^th year. The risk factors for regret are;

• young age
• Single marital status
• Loss of a child
• Divorce
• Women who undergo an immediate postpartum permanent contraception; you should note that your doctor will not accept your request for a permanent contraception when that is made while in labour. Discussion concerning bilateral tubal ligation are usually made during the antenatal care period. In African, you will be asked to seek your partner’s consent.

WHEN IS BILATERAL TUBAL LIGATION DONE?

The decisions regarding timing (interval, postpartum or post-abortion) and surgical approach are made based on patient preference, recent pregnancy, surgical history, and the presence of other medical conditions. Interval permanent contraception is any permanent contraception procedure performed after six weeks of delivery.

Post-abortion permanent contraception is typically performed via laparoscopy immediately following uterine evacuation and postpartum permanent contraception is performed within six weeks of delivery. For an interval sterilization, a woman may already be pregnant when the procedure is performed. This is avoided by scheduling surgery immediately after the menses and by doing a pregnancy test before the operation.

SURGICAL APPROACH FOR BILATERAL TUBAL LIGATION

Surgical approaches for female sterilization include;

• Laparoscopy; in rich resource setting, laparoscopy is used most commonly for interval procedures. Approach here is through small incisions on the abdomen while you are asleep under anaesthesia. A video assisted instrument is passed into the pelvic cavity through this incision to identify and occlude the fallopian tube. It is associated with less pain after the procedure and good cosmetic.
• Hysteroscopy; here the approach is through the vaginal using a video assisted instrument to introduce the material or device that will cause occlusion of the fallopian tube
• Laparotomy; this is done during caesarean section
• Mini-laparotomy; is the most common approach worldwide. The incision is at same location like that of the laparotomy but smaller about 5cm.

COMPLICATIONS OF TUBAL STERILIZATION

Although hysteroscopic sterilization can avoid the risks of a general anaesthesia, laparoscopy and abdominal scars. Potential complications and adverse events include tubal perforation, infection, device migration, device expulsion and vasovagal pain and chronic pelvic pain. Risks of laparoscopic sterilization include failure, risk of injuries to the bowel, bladder and blood vessels. Other complications of tubal ligation are haemorrhage and ectopic pregnancy when it fails.