GYNECOLOGY

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VASECTOMY OPERATION IS THE MALE PERMANENT CONTRACEPTION

Vasectomy operation is the male permanent contraception. It is the male equivalent of bilateral tubal ligation. Vasectomy is also called male sterilization. Although, data has shown an increase in the uptake of vasectomy in the western world, it is yet to be widely accepted in Africa. In fact, I am yet to refer a case to the urologist for one. This is because, I have never succeeded in getting a couple to agree to vasectomy operation.

Even if the man agrees, the woman is often always the one to disagree. This is due to the concern of loss of sexual capacity which the women often express. Despite counseling, this singular concern is always the reason for not accepting vasectomy. These women will prefer to have a bilateral tubal ligation than allow their husbands to have vasectomy.

INDICATION FOR VASECTOMY OPERATION

The indication for vasectomy is when a couple have completed their family size and are in need of a permanent method of contraception. A man who do not want to father a child or who no longer want to have more children and want a permanent contraception is a candidate for vasectomy operation.

CONTRA-INDICATION TO VASECTOMY

A couple that do not accept vasectomy or are undecided will not have it performed on the man. Also, in the setting of emotional instability on the patient, vasectomy should be with hold. If the vas deferens cannot be felt or mobilize for the procedure, vasectomy may not be carry out. The condition that can cause challenge in feeling or mobilizing the vas deferens include; anatomic abnormalities like varicocele or hydrocele, if he had had a previous scrotal surgery or trauma that causes scaring in the scrotum.

In addition, the presence of an active local infection on the scrotum will hinder carrying out the procedure. This will prevent further spread of the infection. A patient on anticoagulant or antiplatelet medications (which are taken to thin the blood to prevent blood clot formation) can increase the risk of bleeding during the procedure or blood clot formation in the scrotum after the procedure. It is important to let your doctor know when you are on these medications.

WHAT TO EXPECT AT VASECTOMY OPERATION?

The procedure is usually done at an outpatient basis. It does not require general anaesthesia. It only requires local infiltration or spray of anaesthetic agent around the site of the procedure. This office procedure does not require hospital admission and has a quick recovery time. The man will be awake during the procedure but will not feel pain.

The vas deferens will be approached through a small opening in the midline. Then, by going through several layers of tissues. The vas deferens is identify and brought out through the small opening created by the use of other instrument other than cutting through. This is called the non-scalpel vasectomy. The vas deferens can be occluded by tying with an absorbable suture and cut, a clip can be applied or by the use of electrocautery.

COMPLICATION OF VASECTOMY

The complication of vasectomy includes

  • Bleeding
  • Infection
  • Collection of blood clot in the scrotum
  • Pain which could be immediate or persistent chronic pain. This usually follows a nerve injury during the operation.
  • Atrophy of the testis can occur as a rare late complication when its blood supply is compromised during the operation.
  • Formation of sperm granuloma which is a small painful nodule at the cut end of the vas deferens near the testis.

WHAT TO DO AFTER THE PROCEDURE

When at home after the procedure, the man should lie down, stay quiet for the remainder of the day, and avoid heavy lifting or exercise for a few days. Ice pack can be applied intermittently to help with pain and swelling. You should call your doctor when you observe any of the above complications.

It should be noted that the man still remains fertile and can impregnate a woman after the vasectomy procedure. To avoid this, additional contraception such as condom is required until sterility is confirmed. Normal sexual activity without additional contraception can begin after 20 ejaculations or two consecutive seminal fluid analysis results done four to six weeks apart shows no sperm in the test sample. It can take up to ten to twelve weeks to achieve sterility.

Some experts recommend only one semen analysis test after twelve weeks. If negative, sterility is confirmed and no need for further test.

FAILED VASECTOMY

Vasectomy is said to have failed if at the follow-up visit after 20 ejaculations motile sperm cells are found on the semen analysis test.

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INFERTILITY AND HOW TO KNOW YOU ARE FERTILE

In this article, infertility and how to know you are fertile. I will explain the signs and symptoms that will point to the possibility of infertility. Pregnancy is the sure confirmation of fertility. There are no specific symptoms or signs that will guarantee that a man or woman is fertile. However, there are certain symptoms or signs whose presence signifies the woman or man will need assistance for the couple to conceive.

For these symptoms and signs, they may be present at the moment or you might have experienced them in the past. Their residual effects might hinder conception.

SYMPTOMS AND SIGNS of INFERTILITY IN WOMEN

A woman who sees her period regularly and experiences premenstrual symptoms such as mood swing, breasts fullness, breasts tenderness, nausea and bloatedness is most likely to be fertile. If she is infertile, it is not likely due to ovulatory dysfunction, which is the common cause of infertility. During the course of evaluation for infertility, certain questions will be asked by the gynaecologist or urologist. These questions are asked to rule in or out the possibility of any medical condition that can cause infertility.

Apart from the inability to conceive, infertility on its own has no particular symptoms or signs. However, the manifestations of other underlying medical condition that can cause infertility are what you can feel and see as the possible symptoms and signs of infertility respectively.

If a woman is unable to conceive with the following symptoms and signs such as; irregular menses; with or without an anterior neck mass; heat (feels hot in cold weather) or cold intolerance (feels cold in hot weather), and excessive weight loss or gain. Thyroid disease may be responsible for these symptoms and signs. Abnormal thyroid hormone interferes with ovulation.

Also, some infertile women may have breast milk coming from the breasts.  Whether they expressed it or it was spontaneous; with or without headache, dizziness or visual disturbance. The likely cause is due to high blood prolactin levels. This high blood prolactin levels could be as a result of tumour in the pituitary or from nipple stimulation. This stimulation can be from direct suckling on the breasts, nipple piercing or herpes zoster involving the chest wall. High blood prolactin interferes with ovulation.

Furthermore, menstrual irregularities associated with abnormal body hair distribution, excessive weight gain, acne with or without voice change is associated with polycystic ovarian syndrome. Women with this condition have very few menses in a year. Some have to shave not only their legs but also their facial hair. These women have excess androgen; the male hormone which is responsible for their male pattern of hair distribution. Their irregular menses is due to the fact that they do not ovulate.

Chronic cyclical pelvic pain that starts some days before the onset of menses, and wanes with the commencement of menstruation, with or without bleeding from other body parts like the navel, is suggestive of endometriosis. This is when the inner lining of the womb is found outside the womb. It bleeds just like the womb during menses. This condition can cause adhesions to form around the fallopian tubes and block the tubes. Therefore, the egg release at ovulation and the sperm cannot meet because the fallopian tubes are blocked. This will result in infertility.

Similarly, Infertility in a woman with a Prior history of pelvic inflammatory disease is due to tubal blockage. Pelvic inflammatory disease is a gynecological emergency because of it after effect on the fallopian tubes and subsequent infertility. It manifest as fever, lower abdominal pain and or swelling with abnormal vaginal discharge. If poorly treatment, it could result in scarring of the fallopian tubes and subsequent infertility.

In addition, pelvic inflammatory disease caused by Chlamydia trachomatis can run a sub-acute course. It will not manifest with the usual symptoms and signs that will prompt health seeking. Also, some individuals can carrier this infection without manifesting any symptoms but will subsequently transmit it to their sexual partners.

SYMPTOMS AND SIGNS OF INFERTILITY IN MEN

The fact that a man can achieve and sustain erection does not make him fertile. This is contrary to the belief that a fertile man should wake up every morning with an erection. Nocturnal penile tumescence commonly called “morning wood” is the erection that men get while sleeping or waking up in the morning. It might signify sexual capacity but not fertility. Some of the symptoms or signs of infertility might have occurred in the past or the man just began to notice these changes.

There are no specific symptoms and signs that signify infertility in a man. However, the presence of certain symptoms and signs in a man whose wife is having difficulty conceiving should be a cause for concern. These may be suggestive of an abnormality in sperm production or transport. These can result in Infertility and these symptoms and signs include:

  • The opening of the urethral may point up or down instead of being at the tip of the penis. This affects proper sperm deposition at the cervix.
  • Sudden reduction in sperm volume can follow retrograde ejaculation or obstruction of the sperm duct. This obstruction could be from inflammatory changes associated with infection involving the urethral, vas deferens or seminal vesicles.
  • Reduction in testicular volume or size may be due to atrophy following trauma, infection causing inflammation of the testis, testicular torsion or reduction in blood supply and oxygen to the testis from complication of sickle cell disease.
  • Inability to achieve and sustain erection may result from diabetes, effect of prolonged priapism (erection) in sickle cell male.
  • Testicular discomfort, swelling or pain and the scrotum might feel like it contains a bag of worms. This is suggestive of varicocele, it affects the sperm structure.
  • Breasts enlargement
  • Discharge of breast milk from a man’s breast, headache and visual disturbances resulting from a tumour in the pituitary gland can result in infertility.
  • Reduce sexual drive from reduce testosterone levels. This can be cause by effects of emotional stress, alcoholism or aging.
THE EFFICIENCY OF THE NATURAL METHODS OF CONTRACEPTION

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THE EFFICIENCY OF THE NATURAL METHODS OF 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 3rd 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.

SPINNBARKEIT; INDICATING THE FERTILE PERIOD

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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INFERTILITY AND SOME OF THE KNOWN CAUSES

Infertility is said to occur when a couple have regular unprotected sexual intercourse of reasonable frequency and are still unable to conceive after one year. A great number of couple will conceive within one year, the remaining small percentage will conceive in the second year. However, evaluation starts after one year for younger women, those ≥35years should be evaluated after 6months of trying to conceive.

The shorter period for evaluating older women has to do with the reduction in the quality of their eggs with age. This affect their chance of conception and also increase their risk of having babies with congenital malformation. A woman’s ability to conceive reduces as she ages.

The period of evaluation will involve extensive history into the sexual and medical history of the couple. The history and examination alone may reveal the cause of the infertility. Both couple are encouraged to attend at least the first consultation. This is where they will be educated on the fertile period where conception is highly likely and also to avoid use of oil based lubricant. This is also an opportunity to commence pre-conception counselling and care.

It is worthy of mention that no sex position increases the chance of conception. Also, there is no need for the women to remain lying either face down or up after intercourse. This does not affect the ability of the sperm to get to the egg. It is also normal to see some seminal fluid coming out of the vagina after sex. The fluid must have serve their purpose; providing the medium for the sperm to swim up to the egg.

As already mentioned in the first article of this series, a couple’s inability to conceive maybe be from one partner or contributed equally by both of them. In certain couples, the cause is not known and this is called unexplained infertility. While the cause of infertility could be sex specific, some of the causes can be found in both sexes.

CAUSES OF INFERTILITY IN MALE

For a man to successfully get a woman pregnant; the testis must be in a state of good health to produce adequate, healthy, motile sperm, the vas deferens must be patent to conduct the sperm and he must be able to achieve erection and ejaculate into the woman’s vaginal. The following are some of the causes of male infertility;

Hormonal disorders: male infertility could result from been born with the absence of the hormone gonadotrophin releasing hormone. The pituitary gland could fail either from the effect of a tumour, radiation or surgery resulting in infertility. Other hormonal causes of male infertility include; thyroid disease, diabetes and high blood prolactin level.

Abnormality of sperm formation: small deletion of one or all the three region on the Y-chromosome that controls the process of sperm formation call spermatogenesis will result in infertility. This deletion could be so small that it may not be detected on karyotyping. Affected males will have reduced sperm or no sperm at all. This may progress from reduced to total absence of sperm resulting in secondary infertility. Other causes of abnormal sperm formation are; mumps infection of the testis, exposure to radiation and testis that fails to descend to the scrotum.

Abnormality of sperm movement: some individuals could be born with defective cilia (Kartagener syndrome); this manifest as male infertility with chronic respiratory infection due to absence of the cilia needed to clear mucus. This also affects the ability of the sperm to move.

Abnormality of sperm passage: some individuals may be born without a vas deferens or their vas deferens may be obstructed later.

Varicocele: the veins in the scrotum are dilated and could give the sensation of a ‘bag of worm’ when felt. This is believed to cause infertility by increasing the temperature in the scrotum. The scrotum by God’s design was kept outside the body for a reason; to have a temperature far less than that of the body. The scrotum need to be at the right temperature for sperm production, motility and proper structure and varicocele interferes with these. Varicocele could manifest with scrotal discomfort or pain.

Sexual dysfunction: reduce sexual desire, retrograde ejaculation (backward emission of semen into the bladder) and erectile dysfunction (inability to achieve and sustain penile erection sufficient for sexual satisfaction) result in infertility. Erectile dysfunction could result from alcoholism as it inhibits sexual response by interfering with testosterone production.

CAUSES OF INABILITY TO CONCEIVE IN FEMALES

For a female to successfully conceive; ovulation must take place, the egg picked up by a fallopian tube, fertilization must occur, transport of a fertilized egg to the womb and implantation of the zygote into the womb. Anything that interferes with this process or passage of sperm into the female genital tract will cause female infertility. The following are some of the causes of female infertility;

Cervical causes: abnormality of the cervix could result from infection, surgical procedure or exposure to radiation. These can result in abnormal narrowing of the cervix or alteration in the production of cervical mucus. The cervical mucus helps the sperm to undergo the changes necessary to penetrate the egg. Some medication such as hormonal contraception, thickens the cervical mucus interfering with sperm passage.

Uterine causes: uterine adhesion from infection, D & C, fibroids in the inner lining of the womb and fibroid removal surgery may result in a partial or complete closure of the cavity of the womb. This interferes with the implantation of the fertilized egg. The uterus may be absence in certain instance or badly malformed in a way that it interferes with implantation.

Ovarian causes: the ovaries may be absent or present but fails to release eggs. Ovulatory dysfunction could result from some endocrine conditions like; thyroid disease, polycystic ovarian syndrome, pituitary disorders (resulting in high prolactin or deficiency of the follicle stimulating and luteinizing hormones), disorder of the hypothalamus resulting in gonadotrophin releasing hormone(GnRH) insufficiency. Other conditions could also alter the release of the GnRH such as high level of stress, starvation, malnutrition, chronic diseases (liver disease, renal failure).

Fallopian tube causes: fertilization takes place in the fallopian tube. The fallopian tubes may be absent or blocked due to infection or from effect of other pelvic tumour. Smoking also interferes with the ciliary action of the cells needed to pick up and move the release egg.

Pelvic causes: pelvic adhesion from previous pelvic surgeries, pelvic inflammatory disease or endometriosis (when the inner lining of the womb is also found outside) can block the fallopian tube or interferes with it motility.

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INFERTILITY HAS NEVER BEEN THE FAULT OF THE MAN

“Infertility has never been the fault of the man”; I don’t know what to call this, a myth or a lie. This has been planted into the psyche of most women that they do unthinkable things to prove how true this generational lie is. You should know that both male and female may contribute to their inability to conceive equally. The cause of the infertility could be due to a male factor, female factor or both. At times, it may be difficult to convince a woman in an African setting that she is not responsible for their childlessness. This belief has permeated our society that even our home movies clearly depict that. 

Also, the attendance of the male partners of couples with infertility to the gynaecology clinic speaks volume. In my facility, patient with complaint of inability to conceive are first seen at the gynaecology clinic. They may be referred to our fertility centre on need basis. It is rare to see a man accompany his wife to the clinic. We have to insist many times we want the spouse to take a seminal fluid analysis test. Sometimes, the woman will finish her evaluation and the man is yet to do his sperm analysis.

At one consultation, after reviewing the woman’s test results, she was told she was fine based on her results. She was not convinced and went ahead to tell me how strong the husband is and that he ‘last long’ in bed. She also brought up another complaint attributing her vaginal discharge to infection and therefore the probable cause of her inability to get pregnant. After another examination, she was found to have a normal vaginal discharge. For this patient, the husband had been invited twice to the clinic which he never showed up. He was also yet to do his sperm analysis.

INFERTILITY; WHEN IS A COUPLE SAID TO BE UNABLE TO CONCEIVE?

The word barren is often erroneously associated with a woman who is unable to bear children, whether it is her fault or not. The real meaning of this word should apply to either the male, female or the couple in a sexual relationship. A couple is declared infertile if they are unable to conceive after one year of regular, unprotected, sexual intercourse. For women who are advanced in age, ≥35years, 6months is used instead of one year. One year is used because about 90% of couples will conceive within one year. It should be noted that the ability to conceive in one menstrual cycle is less than 50% for a fertile couple.

WHEN SHOULD A COUPLE SEEK HELP FOR INFERTILITY?

Generally, after one year of actively trying to conceive, a couple should seek help if they are unable to conceive. For older women, their evaluation should start after 6months of actively trying to conceive. This consideration has to do with the average age of menopause, which is about 45years and the fact that the quality of the woman’s eggs begins to depreciate. While for younger women, their evaluation starts after one year.

However, if the couple feel they have a problem, they can seek help earlier. it is not in all cases that the couple have to wait for 6months or one year. If there is an obvious cause for the couple’s inability to conceive, they will be evaluated and treated. Your gynaecologist will not ask you to mandatorily wait when the cause of the infertility is already known.

WHO SHOULD BE EVALUATED FIRST FOR INFERTILITY?

Contrary to what I have seen in my practice, the male should be tested first. Ideally, the couple should be seen together and their evaluation can go on concurrently. If for any reason one of the couple must be tested first, the male should be the first. This is because it is easier and cheaper to test the male than the female. The evaluation of the female is more expensive, discomforting and takes a longer time. Some of the tests must be carried out at specific periods in her menstrual cycle. For the male, the test can be done at any time except for the sperm analysis that will require a brief period of abstinence.

TYPES OF INFERTILITY

Basically, infertility is classified into two; primary infertility and secondary infertility. A couple is said to have primary infertility if the man had not impregnated his partner in his previous or current relationship, and the woman had not been pregnant ever in her life. Infertility is secondary if either the man had impregnated a woman in the past or his current partner had been pregnant in the past. The outcome of the pregnancy does not matter; whether it resulted in child birth or ended as a miscarriage.

Infertility can also be classified based on which partner is the cause; male factor infertility, female factor infertility, both male and female factors infertility and unexplained infertility.

WHAT ARE THE CAUSES OF INFERTILITY?

For conception to take place; it requires a healthy sperm, healthy egg, normal fallopian tube for the egg to pass and unite with the sperm, and a normal womb for the developing baby to implant and grow. Abnormality that interferes with any of these will result in infertility. One minor but often neglected cause is inadequate sexual exposure.

I once asked a patient how many times in a week she has sexual intercourse since she started trying to conceive. The response was quite funny, she said may be once. If I may ask, for a couple trying to conceive, how many times per week is sex deemed adequate? If your answer is three, you are right, yes you need that much. It is worthy to note that too much of everything is bad including sex. Non-stop daily sex is not recommended, the sperm need some break to accumulate again, a day or two break is fine.

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ORAL HORMONAL CONTRACEPTIVE MEDICATION IS NOT GOOD FOR EVERYONE

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ORAL HORMONAL CONTRACEPTIVE MEDICATION IS NOT GOOD FOR EVERYONE

Left top to bottom: combine pill. Right top to bottom: progesterone only pill

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.

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