Combined oral contraceptives. Methods of contraception. Varieties of oral contraceptives

Oral contraceptives unwanted pregnancy? On the basis of what you need to choose one or another hormonal pill? How does the administration of per oral contraceptives   and for which diseases is it prohibited? Consider these issues.

The benefits of hormonal contraception

1. Reliability. Almost 100% efficiency, subject to the rules of the instructions. And they are very simple:

• take the drug at a certain time (in the morning or in the evening, as it is more convenient) for 21 days, do not miss a dose;
• do not drink medicines that can reduce the effectiveness of the contraceptive (the list contains instructions);
• in case of vomiting, diarrhea that occurred during the first three hours after taking the pill, take another one, because the first one, most likely, was not acquired.

2. Convenience. I took a pill once a day and don’t worry about getting pregnant. Menstruation comes regularly and, if necessary, they can be “rescheduled” if you continue to be taken for a seven-day break.

3. Security. Modern drugs contain a minimum concentration of hormones and can be taken without harm to health for several years, before planning a pregnancy or the onset of menopause. reviews are well tolerated and have only minor side effects.

4. Health benefits. When taking pills, menstruation becomes moderate or even meager. A decrease in blood loss is the prevention of anemia. There is no anemia - a woman feels well, she has good hair and nails.

The purpose of the drug

If you have never taken hormonal birth control pillsBe sure to consult your doctor about this. He will tell you how to choose oral contraceptives in the same place, at the reception, more often even without preliminary tests. The choice of drug does not depend on hormonal background women. That is, there is absolutely no need to take tests for progesterone, estrogen, etc. All drugs have similar composition. Only the content of ethinyl estradiol and the type of synthetic progesterone differ.

There are low-dose monophasic oral contraceptives prescribed for endometriosis, acne, oily hair   and other cosmetic issues. Usually, a doctor has enough conversation with the patient to prescribe the drug. Its financial capabilities are also taken into account. The list of oral contraceptives available on the table of each gynecologist helps to select, if necessary, a generic drug, at a cost much more affordable than the original, but not worse than its quality.

In the first three cycles of taking the drug in a woman, it may periodically appear. This is the so-called addiction of the body. But if the daub persists for more than three months, it makes sense to replace the drug with a higher dosage of ethinyl estradiol, and sometimes with the less popular now three-phase.

Oral contraceptives are contraindicated for a history of thrombosis, diabetes mellitus, severe forms   migraine, a hormone-dependent form of breast cancer in the history or at present, endometrial cancer, serious illnesses   kidney, liver, cardiovascular system.

T.Mack Kay   Birth control   - an integral part of health care. Ideal methods of contraception do not exist, but each married couple can find the one that suits her the most. The doctor, in turn, must introduce the spouses to modern methods of contraception, talk about their advantages, disadvantages and cost. When counseling a woman or a married couple, the doctor must ensure an individual approach and report on all available contraceptive methods, providing an opportunity to choose.

Oral contraceptives
  Oral contraceptives are steroid hormone preparations. They prevent pregnancy by suppressing ovulation. Both estrogens and progestogens can be used. These drugs are often combined, because individually they have to be prescribed in higher doses, which significantly increases the risk of intermenstrual bleeding and other complications. Combined oral contraceptives are taken within 21 days, starting on one of the first 5 days menstrual cycle. The contraceptive effect of oral contraceptives is provided mainly by progestogens. They prevent ovulation, change the condition of the endometrium and the properties of cervical mucus. Estrogens are necessary to shorten the menstrual-like reaction. In addition to monophasic (containing progestogens and estrogens in a 1: 1 ratio), there are two- and three-phase preparations. They contain hormones in different ratios (two-phase for 10 and 11 days, and three-phase for every 7 days of admission). Compared with monophasic oral contraceptives, the total dose of hormones in them is less.
Effect on the body.
  When taking oral contraceptives, biochemical blood parameters can change, which makes it difficult to diagnose a number of diseases. In addition, oral contraceptives can directly affect individual organs, which often serves as the basis for drug withdrawal.

1. Genitals and mammary glands.
   Suppression of ovulation reduces the risk of follicular ovarian cysts. In monophasic oral contraceptives with a low content of hormones and three-phase drugs, this effect is less pronounced. Combined oral contraceptives cause premature secretory transformation of the endometrium, which leads to amenorrhea. Previously used combined oral contraceptives contained high doses of hormones and often accelerated the growth of uterine fibroids. Modern drugs contain less than 0.05 mg of ethinyl estradiol and do not have such an effect. The question of the effect of oral contraceptives on the development of dysplasia and cervical cancer remains controversial. It has been established that oral contraceptives reduce the risk of benign neoplasms of the mammary gland. The risk of developing malignant neoplasms of the mammary gland does not depend on the use of oral contraceptives, however, these drugs can accelerate the growth of an existing tumor. Taking combined oral contraceptives (as opposed to taking mini-pills) inhibits lactation and reduces the content of proteins and fats in milk. The engorgement of the mammary glands, often observed when taking oral contraceptives, is due to the estrogen component. Oral contraceptives reduce the risk by about 2 times inflammatory diseases   genitals.
2. Endocrine glands.
     Under the influence of estrogen, the total content of transcortin and transthyretin in the serum increases. The function of the adrenal cortex and thyroid gland does not change. Oral contraceptives slightly reduce glucose tolerance, but do not increase the risk of diabetes. If there is a history of pregnant diabetes, oral contraceptives are not contraindicated. In patients with diabetes mellitus, the use of oral contraceptives is permissible only in the absence of other contraindications and bad habits. Moreover, during the first week of administration, it is necessary to determine the plasma glucose level daily, and then regularly measure the level of glycosylated hemoglobin. It is better to prescribe oral contraceptives with a weak androgenic effect, for example, containing norgestimate and desogestrel.
3. Other organs.
   Under the influence of oral contraceptives, due to the activation of the renin-angiotensin system, arterial hypertension rarely develops. After discontinuation of the drug, blood pressure usually returns to normal. Possible slight increase in the content of factors VII, IX, X and fibrinogen, as well as a transient increase in some biochemical parameters of liver function. When taking oral contraceptives, cholestasis is approximately as common as during pregnancy. Long reception   drugs increases the risk of certain liver tumors. Chloasma (hyperpigmentation of the skin of the face in the form of a butterfly), which sometimes persists after discontinuation of the drug, can also be observed.

Against the background of taking oral contraceptives, depression, decreased sex drive, nausea, vomiting, and headache may occur. All this is probably due to the effect of drugs on the central nervous system.
Side effects   oral contraceptives are observed quite often, so every woman should be warned about them. Among the side effects sometimes serious, life-threatening, are found. Risk is assessed individually.

1. Severe side effects
   1. Vascular complications
      • Vein thrombosis and pulmonary embolism.
          When taking oral contraceptives, depending on the dose of the drug, the risk of pulmonary embolism increases 3-6 times. As shown by retrospective studies, this is primarily associated with the dose of estrogen in the drug. The duration of oral contraceptives does not affect the risk of vascular complications. If the dose exceeds 0.035 mg, the risk of deep vein thrombosis and pulmonary embolism increases significantly, and soon after discontinuation of the drug it decreases. This is especially noticeable in cases where there are no other risk factors for deep vein thrombosis and pulmonary embolism. Thrombosis of superficial veins when taking oral contraceptives is rare.
      • It was previously believed that the risk of ischemic and hemorrhagic strokes while taking oral contraceptives increases by an average of 2-3 times. However, recent studies have shown that taking low-hormone oral contraceptives does not increase the risk of this pathology in healthy women. Severe and persistent headache is an indication for the abolition of oral contraceptives, since it may precede a violation of cerebral circulation.
      • In women older than 35 years of age who smoke or suffer from diabetes mellitus, arterial hypertension or hyperlipoproteinemia, taking oral contraceptives increases the risk of myocardial infarction. In studies conducted in Walnut Creek and Paget Sound, there was no association between oral contraceptives and myocardial infarction. It is believed that in women older than 35 years (not having the above diseases) and in women under 35 years of age, taking oral contraceptives does not increase the risk of myocardial infarction.
   2. Tumors
      • Tumors of the liver.
          A connection has been established between taking oral contraceptives and the occurrence of liver adenoma. The risk of the disease is directly proportional to the dose of estrogen and the duration of oral contraceptives. The tumor is abundantly vascularized and dangerous by internal bleeding. Although liver adenoma is extremely rare, every woman taking oral contraceptives should be sure to palpate the liver during annual examinations. If liver adenoma is suspected, CT and MRI are performed. After withdrawal of oral contraceptives, the tumor usually regresses. It has been suggested that hepatocellular carcinoma is associated with oral contraceptives. However, the risk of the disease is low, since in young women this tumor is extremely rare. In addition, since the 60s, when oral contraceptives began to be used in the USA, the incidence of hepatic cell carcinoma did not increase.
      • Mammary cancer.
          The effect of oral contraceptives on the incidence of breast cancer has been studied in more detail. In most studies, in particular the extensive study, “Cancer and Steroid Hormones,” it was found that oral contraceptives do not increase the risk of breast cancer. Moreover, hormonal contraception may even reduce the risk of this disease in postmenopausal women - a period when the disease is more common. However, there have been a number of reports that the risk of breast cancer with prolonged use of oral contraceptives in childbearing age increases. These reports were quite contradictory, since an increased risk of the disease was found in women in different subgroups (allocated on the basis of age and a number of other characteristics).
      • Ovarian and uterine cancer.
          It has been found that if you take oral contraceptives for a year, the relative risk of endometrial cancer is reduced to 0.5, and ovarian cancer to 0.6. Similar results were noted in almost all studies. The risk of ovarian and uterine body cancer begins to decrease after 3-6 months of taking oral contraceptives and continues for at least 15 years after they are canceled.
      • Cervical cancer.
          Oral contraceptives are thought to slightly increase the risk of dysplasia and cervical cancer. However, this issue remains controversial, since most studies did not take into account important risk factors for the disease (a large number of sexual partners, early onset of sexual activity, smoking). Nevertheless, patients taking oral contraceptives annually conduct a cytological examination of a smear from the cervix, stained according to Papanicolaou.
   3. Arterial hypertension.
        In most women, blood pressure rises slightly. A marked increase in blood pressure is rare and, obviously, is associated with the activation of the renin-angiotensin system under the influence of estrogens. Women taking oral contraceptives need a frequent measurement of blood pressure, especially in the first months. Already existing hypertension and smoking while taking oral contraceptives increase the risk of other cardiovascular diseases. Anamnestic indications of an increase in blood pressure during pregnancy are not considered a contraindication to hormonal contraception.
   4. After the abolition of oral contraceptives, amenorrhea is observed in 0.2-0.10% of cases. In this case, an examination is indicated, especially if amenorrhea is accompanied by galactorrhea.
2. Other side effects   include intermenstrual spotting, nausea, vomiting, weight gain.
   1. In the first 3 months of taking oral contraceptives, intermenstrual bleeding is often observed. If they occur in the first half of the menstrual cycle, this is due to the low estrogen content in the drug, and in the second half of the cycle, to the low progestogen content. If discharge is observed for more than three months, it is better to change the drug. Since intermenstrual bleeding is caused by atrophy and decidual-like transformation of the endometrium, estrogens (for example, 0.02 mg of ethinyl estradiol) can be additionally prescribed for 1-3 menstrual cycles.
   2. Nausea and vomiting are caused by estrogens and usually occur in the first months of taking oral contraceptives. In this case, the dose of estrogen is reduced or oral contraceptives are taken at a certain time - at dinner or at bedtime.
   3. Weight gain. The reasons are fluid retention under the influence of estrogens and progestogens, excessive deposition of fat in the subcutaneous tissue under the influence of estrogens, as well as increased appetite due to the anabolic action of a number of progestogens. For the prevention of weight gain, the correct selection of the drug, a low-calorie diet and sufficient physical activity. Weight loss while taking oral contraceptives can be observed as often.

Absolute contraindications   to the appointment of oral contraceptives.

1. Thrombophlebitis, pulmonary embolism, history of hemorrhagic stroke or coronary artery disease.
2. Liver failure.
3. Suspected estrogen-dependent neoplasms (breast cancer, cancer of the uterus, liver adenoma, etc.).
4. Pregnancy.
5. Anamnestic indications of pregnancy cholestasis.

To the appointment of oral contraceptives.

1. Arterial hypertension.
2. Epilepsy.
3. Diabetes mellitus or diabetes of pregnant women.
4. Migraine while taking oral contraceptives.
5. Over 35 years old combined with risk factors such as diabeteshypertension, hyperlipoproteinemia, or smoking.
6. The upcoming extensive operation.
7. Hyperlipoproteinemia or myocardial infarction in close relatives under the age of 50 (parents or siblings).
8. Uterine bleeding of unknown etiology.
9. Sickle cell anemia.
10. k. Chronic cholecystitis with frequent exacerbations.

Drug selection

1. When prescribing oral contraceptives, the following must be remembered.
   1. It is better to prescribe a drug with a low estrogen content, since most of the side effects are associated with this component.
   2. Mini-saws are less effective than combined oral contraceptives.
2. Even with relative contraindications, women are advised to choose a different method of contraception. You should start with a drug containing not more than 0.035 mg of ethinyl estradiol. Before taking oral contraceptives, a woman is advised to read the instructions and recall that if a headache, visual impairment, pain in the legs, abdomen or behind the sternum occurs, she should immediately consult a doctor. In the absence of complaints, a control examination, including palpation of the mammary glands and abdomen, as well as a gynecological examination, is carried out after 3 months. Be sure to measure blood pressure and conduct a cytological examination of a smear from the cervix with Papanicolaou coloring. In the future, control examinations are carried out annually.
3. Mini-pills are oral contraceptives containing only progestogens. They are prescribed when estrogens, and therefore combined oral contraceptives, are contraindicated. The disadvantages of these drugs are a high risk of menstrual irregularities and lower efficacy compared with combined oral contraceptives. Nevertheless, mini-drank is a fairly effective method of contraception, indispensable for some women.

Other hormonal contraceptives

1. Norplant is a subcutaneous implant consisting of 6 silicone capsules each 34 ґ 2.4 mm in size. Capsules contain levonorgestrel, which over the course of 5 years gradually enters the blood (0.08 mg / day). Capsules are implanted under the skin of the inner surface of the shoulder and removed after 5 years. Norplant's effectiveness ranges from 0.2 pregnancy per 100 women during the first to 1.1 pregnancy per 100 women during the fifth year of use. Norplant does not contain estrogens, so it can be used with a pronounced side effect of combined oral contraceptives. Norplant is ideal for women who want to achieve long-term contraception, but refuse sterilization. Since intermenstrual bleeding, headache and weight gain may appear in the first months of using Norplant, a woman should be warned about this and cautioned against premature implant removal. Contraindications to the use of Norplant - taking anticonvulsants (with the exception of valproic acid), suspected breast cancer. Before prescribing the drug, pregnancy should be excluded. While taking Norplant, it is possible to exacerbate diseases such as migraine and acne.
2. Medroxyprogesterone is a highly effective progestogen approved for use as a contraceptive in more than 90 countries, including the United States. 150 mg / m every 3 months is usually prescribed for contraception. The effectiveness is 0.4 pregnancy per 100 women during the year. It is necessary to warn a woman about side effects   the drug. The most common of these is amenorrhea. Intermenstrual bleeding may occur, which often causes drug discontinuation. Side effects also include weight gain, headache, and irritability. Contraindications to the appointment of medroxyprogesterone - uterine bleeding of unknown etiology. Before prescribing the drug, pregnancy should be excluded. A WHO study showed that the drug does not increase the risk of breast cancer.
3. New hormonal contraceptives (injectables and implants) are currently emerging. These include, for example, long-acting injectable estrogen-progestogen contraceptives. Their advantage is a low risk of intermenstrual bleeding. In addition, biodegradable capsules (granules) are being developed for implantation, which contain progestogens and provide a contraceptive effect for a year, as well as injection contraceptives in the form of biodegradable progestogen-containing microspheres, which provide the drug for 3 months.

Intrauterine contraception
  The mechanism of action of intrauterine contraceptives is not fully understood. They do not affect either ovulation or the production of steroid hormones. It was previously believed that intrauterine contraceptives interfere with implantation of a fertilized egg. According to studies, they are most likely to act at an earlier stage, disrupting the movement of the egg or sperm.

1. The effectiveness of intrauterine contraception averages 1-2 pregnancies per 100 women during the year (according to some sources, from 0.5 to 3). Inefficiency is due to improper administration or unnoticed spontaneous expulsion of intrauterine contraceptives.
2. Complications
     The most serious complications are inflammatory diseases of the genital organs. Sometimes cramping pain in the lower abdomen and uterine bleedingthat requires the removal of intrauterine contraceptives.
   1. Inflammatory diseases of the genital organs against the background of intrauterine contraception occur more often than when using other methods and in the absence of contraception. Based on the data of the Women's Health Study, it was estimated that among women using intrauterine contraceptives, the relative risk of inflammatory diseases of the genital organs in promiscuous people is 2.6, and for those with a permanent sexual partner - less than 1.8. In addition, the risk of inflammatory diseases of the genital organs temporarily increases in the first months of using intrauterine contraceptives (due to bacterial contamination during administration), and then gradually decreases. Genital inflammatory diseases can occur on different terms   after the introduction of intrauterine contraceptives. Their occurrence in the early stages of contraception can be prevented by the prophylactic administration of antibiotics, for example, doxycycline, 200 mg orally 1 hour before the introduction of intrauterine contraceptives. Inflammatory diseases of the genital organs against the background of intrauterine contraceptives are often associated with sexually transmitted infections. Signs of inflammatory diseases of the genital organs can be fever, pain in the lower abdomen, pain on palpation, and spotting from the genital tract. The woman is warned that if such symptoms appear, she should immediately consult a doctor. When the diagnosis is confirmed, the detachable canal of the cervix and vagina (smears and culture) is examined and antimicrobial therapy is started. Intrauterine contraceptives are usually removed. In severe cases, the patient is hospitalized.
   2. Intrauterine contraceptives that do not contain progesterone or copper are more often subjected to spontaneous expulsion (they are no longer released in the United States). This usually occurs during the first year (1-8% of cases), more often in the first 3 months after administration. Expulsion can occur imperceptibly, therefore, after each menstruation, and in the first 3 months - more often, a woman should check whether the threads of intrauterine contraceptives hang from the cervical canal.
   3. Uterine perforation is a rare complication. Its risk can be reduced if, before the introduction of intrauterine contraceptives, the position of the uterus is determined using bimanual examination and sounding, and during the introduction of the contraceptive, the cervix is \u200b\u200blowered to the entrance to the vagina by bullet forceps. Perforation is usually asymptomatic and is detected only with the disappearance of excretory threads or pregnancy. The localization of intrauterine contraceptives is clarified using ultrasound or radiography. Despite the fact that if an intrauterine contraceptive enters the abdominal cavity, the risk intestinal obstruction   small, its surgical removal is indicated. Remove intrauterine contraceptives from abdominal cavity   it is possible during culdoscopy (if the contraceptive is located behind the uterus) or laparotomy.
3. Pregnancy
     If pregnancy occurs when using intrauterine contraceptives, a woman must be warned about the following.
   1. The onset of pregnancy is often ectopic. This is due to the fact that intrauterine contraceptives better protect against normal pregnancythan from an ectopic. The risk of ectopic pregnancy with the use of intrauterine contraceptives does not increase.
   2. The removal of an intrauterine contraceptive is indicated. Immediate removal reduces the risk of spontaneous abortion (from 50% to approximately 25%). Pregnancy when using intrauterine contraceptives is associated with a risk of serious infectious complications (most often in the second trimester of pregnancy). If during examination of the cervix, the threads of the intrauterine contraceptive are not visible and it is not possible to capture them with tweezers in the cervical canal, it is recommended to terminate the pregnancy.
4. Selection of an intrauterine contraceptive.
     In the United States, two types of intrauterine contraceptives are used: Progestasert (contains progesterone) and Paraguard (contains copper). Lipps loop has recently been removed from the US distribution network.
   1. Progestasert is a T-shaped intrauterine contraceptive containing 38 mg of progesterone. Progesterone gradually enters the bloodstream (at 0.065 mg / day). Contraceptive effect lasts about a year. The effectiveness is 2.9 pregnancies per 100 women during the year.
   2. The paraguard also has a T-shape, the rod and its shoulders are wrapped in copper wire. This is one of the most effective intrauterine contraceptives. Its effectiveness is 0.5 pregnancy per 100 women during the year. Clinical trials have shown that the contraceptive effect of Paragard can last for 8 years, but based on the FDA recommendation, the term of use is limited to 4 years.
5. Intrauterine contraceptive administration.
     Before the procedure, a written consent of the woman is obtained. For this, manufacturing companies issue forms with detailed information about each intrauterine contraceptive. After reading the information, the woman signs the form. The doctor also signs and saves the form on her medical record. The method of introducing intrauterine contraceptives is described on leaflets. For the convenience of administration and to reduce the risk of uterine perforation, each contraceptive has a special mechanism. General rules   the introduction of intrauterine contraceptives is as follows.
   1. In a bimanual study, the position of the uterus is determined, pregnancy and inflammatory diseases of the genital organs are excluded. An intrauterine contraceptive can be administered at any position of the uterus, however, in the case of unrecognized retroflexion, the risk of perforation is high.
   2. Having exposed the cervix with mirrors, they treat it with an antiseptic solution.
   3. Before applying forceps for anesthesia, 1 ml of 1% lidocaine solution is injected into the anterior lip of the cervix and 5 ml of solution paracervically on each side for four and eight hours. Having captured the front lip of the cervix with bullet forceps, the length and direction of the uterine cavity are determined using a probe.
   4. Following the attached instructions, under aseptic conditions, an intrauterine device is placed in a special conductor.
   5. Holding the bullet forceps, the conductor is inserted through the cervical canal into the uterine cavity to its bottom.
   6. Release the contraceptive threads and carefully remove the conductor.
   7. Cut the contraceptive threads at a distance of 2.5 cm from the external pharynx.
     Use of intrauterine contraception is recommended to give birth. In this case, contraception is easier to introduce, and spontaneous expulsion is less common. In addition, infertility due to inflammatory diseases of the genital organs does not have such tragic consequences as in those who did not give birth. The woman is explained that if bleeding from the genital tract or pain in the lower abdomen, she should immediately consult a doctor. With inflammatory diseases of the genital organs, severe pain   or a bleeding contraceptive should be removed.
6. Absolute contraindications to the introduction of intrauterine contraceptives.
   1. Acute, including recent exacerbation, or often recurrent inflammatory diseases of the genital organs.
   2. Pregnancy. It is better to introduce intrauterine contraceptives during menstruation or during the first 2 weeks of the menstrual cycle. If pregnancy is excluded, a contraceptive can be entered on any day of the menstrual cycle.
7.   Relative contraindications
   1. Suspicion of malignant neoplasms of the genital organs: bleeding from the genital tract, detection of atypical cells during cytological examination of smears from the cervix, stained by Papanicolaou.
   2. Sexually transmitted diseases, recent infectious complications of abortion and postpartum endometritisas well as risk factors for inflammatory diseases of the genital organs: a large number of sexual partners or a predisposition to infection (for example, with diabetes mellitus, treatment with corticosteroids).
   3. Ectopic pregnancy   in the anamnesis.
   4. Hemostasis disorders or anticoagulant treatment.
8. Other relative contraindications   include heart defects, deformation of the uterine cavity (with myoma or malformations), severe menorrhagia, algomenorrhea and a lack of history of pregnancy. Another contraindication is HIV infection. There is an assumption, although unreasonable, that with AIDS, the risk of inflammatory diseases of the genital organs increases. In addition, when using intrauterine contraception, abundant menstruation and intermenstrual bleeding are possible, which increases the risk of HIV infection for the partner.

Barrier methods
Vaginal diaphragm and spermicides.
  The diaphragm is a thin latex cap surrounded by a dense spring ring coated with rubber. It is put on the cervix before intercourse. The diaphragm is inserted into the vagina in a compressed form, where it straightens out, repeating the contours of the walls. The diameter of the ring is from 50 to 95 mm, so the diaphragm is selected individually. Since the diaphragm creates only a mechanical obstacle to the sperm, it should be treated with spermicides, which significantly increases the effectiveness of contraception. The diaphragm is removed no later than 24 hours after administration. Theoretical effectiveness is 3 pregnancies, and clinical - 18 pregnancies per 100 women during the year. Using a diaphragm does not usually cause severe complicationsalthough toxic shock cases have been described when the diaphragm remained in the vagina for more than 36 hours. The diaphragm compresses urethra and affects the microflora of the vagina. In this regard, the risk of infection is almost 2 times higher urinary tract. It is shown that spermicides do not have teratogenic effects.

1. Application.
     During a vaginal examination, the doctor determines the distance from the posterior vaginal fornix to the posterior surface of the pubic symphysis and selects a maximum diaphragm that can fit easily between these anatomical points. Then the woman tries to enter the diaphragm on her own, directing her backward. If the diaphragm is directed forward, the neck will impede the insertion. Having entered the diaphragm into the posterior arch, the woman brings her front rim under the pubic symphysis, and with the index finger checks whether the diaphragm closes the cervix. The diaphragm can be entered long before sexual intercourse, and immediately before it. It should be removed no earlier than 6-8 hours after intercourse. Before administration, the inner surface of the diaphragm is lubricated with spermicidal cream or gel. If repeated sexual intercourse is possible within the next 6 hours without removing the diaphragm, an additional amount of spermicide is introduced into the vagina. A woman is taught self-introduction and removal of the diaphragm.
2. Contraindications.
     Relative contraindications - prolapse of the vagina, cysto-and urethrocele. In case of toxic shock in the history and recurrent urinary tract infection, it is better not to use the diaphragm.

Cervical cap.
  The cervical cap has the shape of a bowl. In the United States, only four sizes of caps are available — diameters from 22 to 31 mm. Since the cap should fit snugly against the cervix, finding the right size can be difficult. The technique for administering the cap is not easy; training a woman usually takes at least 1 hour. The pregnancy rate for nulliparous women is approximately the same as when using the diaphragm, and for those giving birth it is much higher.

1. Application.
     Since the cap is held on the cervix by suction, it must be precisely sized. One third of the cap is filled with spermicidal gel or cream and put on the cervix several hours before sexual intercourse. The agent is effective within 48 hours after administration. After intercourse, check the position of the cap and leave it for several hours (but no longer than 24). To remove the cap, press on its edge.
2. The use of the cap is impossible in the following cases: it is not possible to select the desired size, it is not possible to enter it correctly, there is deformation of the cervix. Contraindications include a history of toxic shock, recurrent inflammatory diseases of the genital organs, latex allergy, and spermicides. Since when using the cap, it is possible to change the cytological picture of smears from the cervix stained according to Papanicolaou, women using this method of contraception regularly (at least 1 time in 3 months) take smears from the cervix.

Male condom.
  Theoretical effectiveness is 3, and clinical - 12 pregnancies per 100 women during the year. To increase the contraceptive effect, a condom is used in combination with a spermicidal cream, gel or foam. Due to the growth of sexually transmitted diseases (in particular HIV infection), in the United States this method of contraception is becoming more common. A condom reduces the risk of gonorrhea, chlamydial infection, HIV infection, hepatitis B and herpes. To prevent the transmission of viruses, do not lubricate the condom with petroleum jelly.

1. Application
   1. A condom is put on the penis, which is in a state of erection.
   2. Immediately after ejaculation, but before reducing the erection, the penis should be removed from the vagina, holding the condom by the rim.
2. Disadvantages of the method   - latex allergy and decreased sexual satisfaction. In such cases, other methods of contraception are recommended.

Female condom   made of polyurethane. At both ends, one of which ends blindly, there are flexible polyurethane rings. The approximate size of the condom: diameter - 8 cm, length - 17 cm. The blind end is inserted deep into the vagina. The effectiveness of the female condom is the same as that of other barrier methods.
Contraceptive foam.
  Thanks to spraying, contraceptive foam is more effective than gel or cream. Among spermicides, foam is the only form of release that can be used independently, without combining with other methods of contraception. Theoretical effectiveness is 2 pregnancies per 100 women during the year, and clinical - more than 30.

1. Application.
   Foam is injected into the vagina shortly before intercourse. Before use, shake the bottle thoroughly and check the spray quality. The applicator is injected deep into the vagina, then it is advanced back 1-1.5 cm and the drug is sprayed. Spermicides cause impaired motility and death of sperm. Within 6-8 hours after intercourse, you can not wash yourself.
2. Disadvantages of the method.
     Reports of teratogenicity of spermicides (with accidental use in the early stages of pregnancy) have not been confirmed. Allergic reactions are occasionally observed. Foam has an unpleasant taste, which can interfere with oral sexual intercourse.

Vaginal suppositories and filmscontaining spermicides are similar in effectiveness to foam.
Contraceptive sponge   - This is a polyurethane sponge soaked in nonoxynol. It is inserted into the vagina not earlier than 24 hours before sexual intercourse. The contraceptive effect is ensured by the destruction of sperm by nonoxynol, a mechanical barrier to sperm, and sperm absorption. All sponges have a standard size, individual selection is not required. Since the effectiveness persists throughout the day, the sponge can be used for several sexual intercourse. The effectiveness in nulliparous women is approximately the same as when using other barrier methods, and in women giving birth it is much lower.

Rhythmic methods
  Rhythmic methods are based on determining the time of ovulation and limiting sexual intercourse during this period. Successful use of rhythmic techniques requires attention and experience. For some couples, it may be important that these methods are approved by the Roman Catholic Church.

1. Calendar method. Initially, the duration of the menstrual cycle is determined within 6-12 months. As you know, ovulation occurs 12-16 days before the start of the next menstrual cycle, the egg lives 24 hours, and the sperm 48 hours. Therefore, the beginning of the fertile period can be determined by subtracting 18 days (16 days plus 2 days of sperm viability) from the shortest the menstrual cycle, and the end of the period - subtracting 11 days (12 days minus 1 day of egg viability) from the longest menstrual cycle. For example, if the menstrual cycle lasts 24-34 days, you should avoid sexual intercourse from the 6th day of the menstrual cycle (24 - 18 \u003d 6) to the 23rd day (34 - 11 \u003d 23), i.e. 17 days. Theoretically, this period covers all days when pregnancy can occur, and the less regular the menstrual cycle, the longer the period of abstinence. The effectiveness of the method is about 40 pregnancies per 100 women during the year. The disadvantages of the method include a long period of abstinence and low efficiency.
2. Measurement basal temperature . If the menstrual cycle is regular, the dynamics of basal temperature (the temperature measured in the rectum in the morning at the same time, before eating) has the form of a two-phase curve. Immediately after ovulation, the basal temperature rises by 0.3-0.5 ° C. If it remains elevated for another 3 days, then ovulation has indeed occurred and the remaining period of the menstrual cycle is safe. Basal temperature measurement can be used as independent method   contraception, but more often it is combined with others.
3. Assessment of cervical mucus. The properties of cervical mucus change throughout the menstrual cycle. Before and after ovulation, it is thick and viscous, and during ovulation it is watery and viscous. The safe period is determined by the termination of ovulatory secretions. When the nature of the discharge changes (against a background of infection or topical application medicines) errors are possible
4. Symptothermal Method   combines elements of the above rhythmic methods. A woman needs to measure basal temperature and monitor the nature of cervical mucus. They abstain from sexual intercourse from the moment ovulatory secretions appear, and resume them from the 3rd day after the increase in basal temperature or the 4th day from the peak of ovulatory secretions. Ovulation can be determined by other signs: pain in the lower abdomen, scanty spotting from the genital tract, swelling of the vulva and engorgement of the mammary glands. It is also characterized by softening and a slight opening of the cervix, its displacement deep into the vagina.

Other methods

1. Interrupted sexual intercourse   - a long-known, but unreliable method of contraception. Clinical efficacy is 18 pregnancies per 100 women during the year. Disadvantages of the method - the pre-ejaculatory secret often contains sperm, sexual intercourse is not always possible to interrupt on time. In addition, one or both partners often experience emotional discomfort. Advantages - free and affordable in any situation.
2. Lactation also protects against pregnancy. With regular natural feeding, lactational amenorrhea can be maintained for two years after childbirth. Studies conducted in Rwanda showed that in 50% of women in the absence of lactation, the next pregnancy occurred within 4 months after childbirth, and 50% of women who had lactation did not become pregnant more than 18 months after birth. Despite this, it is hardly possible to recommend natural feeding as a method of contraception.

Postcoital contraception
  Postcoital contraception includes various methods of pregnancy prevention, which are used after sexual intercourse.

1. Postcoital douching is an unreliable method. In the cervical mucus, sperm can appear as early as 90 s after ejaculation.
2. For hormonal postcoital contraception, oral contraceptives containing a combination of ethinyl estradiol with norgestrel (or levonorgestrel) are used. The total dose of ethinyl estradiol should be 0.2 mg, norgestrel 2.0 mg, and levonorgestrel 1.0 mg. The dose is divided in half and taken at intervals of 12 hours no later than 72 hours after sexual intercourse. The effectiveness of the method is quite high.
3. Intrauterine contraceptives containing copper are administered no later than 5 days after sexual intercourse. After rape, intrauterine contraceptives are used as postcoital contraception only in combination with preventive antimicrobial therapy, since in this case there is a high risk of inflammatory diseases of the genital organs.

Artificial abortion
Definition and indications
Artificial abortion - intentional termination of pregnancy before the term of viability of the fetus. In the USA since 1973, abortions in the II trimester of pregnancy are allowed. Thus, artificial abortion is an abortion of up to 26 weeks, performed at the request of the woman and in accordance with the law. Artificial abortion is not always performed for medical and social reasons (when there is a threat to the health of the woman or fetus). Often parents are pushed to this step by the inability or unwillingness to take responsibility associated with the bearing and further education of the child.
Absolute readings   for artificial abortion are rare. Usually it is severe heart failure, severe arterial hypertension, especially with damage to the myocardium, retina and kidneys, and severe chronic renal failure.
Relative indications   for artificial abortion can serve severe course   chronic lung diseases and non-specific ulcerative colitisas well as breast cancer. Abortion is also indicated for some mental disorders. Today, most of the induced abortions are performed according to relative indications.
The choice of method depends on the duration of pregnancy. Than less timethe safer the abortion. In addition, contraindications to one or another method of abortion are taken into account.

1. Methods of abortion: vacuum aspiration, curettage of the uterus, intravaginal or intraamnial administration various means. Hysterotomy as a method of artificial abortion is practically not used due to a sharp increase in the risk of complications and death of a woman. In Western Europe, mifepristone in combination with prostaglandins is used for medical termination of pregnancy. In addition, abortion is possible with the use of methotrexate in combination with prostaglandins (the method is in clinical trials).
2. The decisive factor for choosing a method of abortion is its duration. Vacuum aspiration can be used (depending on the experience of the doctor) until the 15th week of pregnancy. The use of this method at a later date increases the risk of bleeding and perforation of the uterus. At a period of 16-24 weeks of pregnancy, curettage of the uterine cavity is used. With sufficient experience, this method is the safest. Nevertheless, some authors prefer other methods, for example, intravaginal administration of prostaglandins.

For the prevention of Rh sensitization all women with Rh-negative blood that do not have anti-Rhesus antibodies are injected with anti-Rh0 (D) -immunoglobulin v / m within 72 hours after abortion. If the gestational age is less than 12 weeks, 0.05 mg of the drug is enough, in a later date, the dose is increased to 0.3 mg.

Sterilization
  Since the use of oral contraceptives and intrauterine contraceptives is fraught with complications, many married women who no longer want to have children prefer sterilization. About 1 million of such operations are performed annually in the United States, of which about 60% are for women.
For sterilization   There are strict legal restrictions set forth in state laws. In 1979, the US government passed the Sterilization Act, which states the following.

1. The person who is to be sterilized must be at least 21 years old.
2. He must be mentally healthy.
3. From the moment of signing the documents before the operation should pass at least 30 days. If, after obtaining the woman’s consent for sterilization, a premature birth occurs or surgery is required, a reduction in the term is allowed (at least 72 hours).
4. It is forbidden to obtain consent during childbirth or in the case when a woman wants to terminate the pregnancy.

Sterilization methods

1. Woman sterilization. Almost all sterilization methods consist in artificial violation of patency fallopian tubes. Sterilization can be done immediately after birth or later. The most common method is tubal ligation according to the Pomeroy method (crossing the fallopian tubes between two ligatures). For some gynecological diseases   and unwillingness to have children produce uterine extirpation. Up to 20% of women who have undergone sterilization request restoration of fertility. The operation is possible only in 20-30% of cases, of which the ability to give birth to children can actually be restored only in 51-73% of the newly operated.
2. Male sterilization. 40% of all sterilizations in the US are performed by men. The operation is performed on an outpatient basis under local anesthesia. Through small incisions of the skin, the scrotum secreted on both sides of the vas deferens and impose two ligatures on each. Then the ducts cross between the ligatures, and the ends of the stumps coagulate. No lethal outcomes were noted, complications are rare, the most common of them is hematoma. The method is effective in more than 99% of cases. It is possible to restore fertility after surgery, but it is better for the man to consider sterilization irreversible.

Selection of a method of contraception
The selection of the method of contraception is carried out individually. The main criteria for choosing a method are safety and effectiveness. For example, if there is a high risk of sexually transmitted diseases, regardless of the chosen method of contraception, it is recommended to combine it with the use of condoms.
Safety is assessed on the basis of the degree of risk of complications and mortality associated with both the method itself and the consequences of an unwanted pregnancy (if the method is ineffective). Correct assessment of indications and contraindications can significantly reduce the risk of complications when using oral contraceptives and intrauterine contraceptives. The use of barrier methods of contraception is rarely accompanied by complications, however, due to the lower reliability of these methods, the risk of other complications associated with pregnancy and abortion increases.
The effectiveness of the method mainly depends on its proper use. Oral contraceptives, if taken without errors, protect against pregnancy in almost 100% of cases. However, due to inaccuracies in taking the drug, the effectiveness of oral contraceptives may even be lower than with the correct use of barrier methods. When giving recommendations, it is always necessary to consider the convenience of the method. For example, if partners cannot always use barrier methods or oral contraceptives correctly, it is best to recommend intrauterine contraceptives.
Sterilization is the method of choice for couples who no longer wish to have children. Those who choose sterilization are reminded of the irreversibility of this operation. Although fertility recovery is possible, such interventions are expensive and often ineffective. In addition, with any operation, even a small one, there is a risk of death.