Population control is one of the burning problems facing India today.  While there are a plethora of contraceptive methods today each one has its own drawbacks.  The average doctor still has many doubts about contraceptive methods, which have remained uncleared.  Meanwhile the search for the perfect contraceptive continues.  In the following section a few of the problems that could face a practitioner are spelt out with possible solutions.

 Natural methods of contraception:

 The natural methods are the Rhythm method, the Basal body temperature method and the cervical mucus method.  The rhythm method is the method commonly used.  In this method intercourse is avoided on possible days of ovulation. Ovulation is said to take place about 14days+/- 2 days before the next period.  The period of the second half of the cycle between ovulation and the menstruation that follows is more or less fixed.  However variations in the menstrual cycle are common in the perimenopausal women, and at times of stress, travel,and medication. Failure rates are high in the natural methods of contraception.

Vaginal sponge method

 In India, “Today” is the most popular vaginal sponge in use.  It is a soft disposable foam sponge made of polyurethane.  It has an attached nylon loop which helps in its removal.   It is moistened with water, squeezed gently to remove excess water and inserted high up in the vagina to cover the cervix.  It acts for 24 hours and intercourse may be repeated as often as desired during this period.  Failure rate varies between 9 and 27 per 100 users in the first year.  It must be removed and thrown away after 8-24 hours but not before 6 hours of the last act.

Intrauterine contraceptive device (IUD)

Timing:

 An IUD should be ideally be inserted post menstrually, so that insertion in the early stage of pregnancy is avoided. But a patient  should not be refused insertion at other times as she may get pregnant before the next menstruation.

Postcoital: To prevent or interrupt pregnancy following unprotected intercourse IUD’s have been inserted up to 5 days after coitus.

Post-abortal: Studies in various countries and by WHO showed no increased incidence of infection, perforation, expulsion, bleeding or other events following insertion of IUD after spontaneous or induced abortion. However, in patients who can come for follow up, the author would prefer to wait for the next cycle to insert an IUD.  In case the patient gets irregular bleeding after the abortion, it may be due to endometritis/incomplete evacuation, but with an IUD in situ, it becomes difficult to convince the patient to continue using the IUD. s it may be prudent to wait for post abortal events to settle before inserting an IUD.

Post partum:  Both postpartum and interval insertion after caesarian delivery have been found to be safe and effective, but there is a higher expulsion rate.  Most authorities advocate insertion after 6 weeks of delivery.  Following caesarian section it is better to introduce IUD after 3 months of delivery. 

IUCD bleeding:

 Citrus bioflavonoid compounds (Gynae CVP) in the dose of one capsule thrice daily or pure synthetic diosmin (Venusmin) in the same dose may be useful.  The author has found proprietary ayurvedic uterine tonics useful in such cases.

Intermenstrual bleeding with IUD usually passes off in a month and only reassurance is necessary.

Pelvic pain  following IUD insertion:

A careful pelvic examination should be done.  If there is tenderness in one of the fornices, there could be pelvic infection.  The IUD should be removed and antibiotics effective against both aerobic and anaerobic infections like metronidazole and ampicillin or cephalosporins for a course of 10-14 days is recommended.  On examination, if the thread of the IUD is not seen, an X-ray or an USG will confirm if the IUD is correctly positioned.  If it is not, a perforation could have occurred and the IUD removed.  If it is in position, and on  pelvic examination there is no tenderness, the pain could be due to uterine cramps which can be relieved with antispasmodics or NSAIDs. Even if there is no history of amenorrhoea it is mandatory to do a urine pregnancy test to rule out the possibility of ectopic pregnancy.  If pregnancy test is negative, pelvic infection should be looked for. and treated.. The position of the IUCD should be checked to make sure it has not got displaced.  

 Since polymenorrhoea is usually due to local inflammatory reaction, NSAIDs in the dose usually used for ovulatory bleeding may be enough to cure it. This will also take care of uterine cramps if they are the source of lower abdominal pain. Bioflanoids (Gynae CVP) could be added. Iron should be added to prevent anaemi

Pregnancy with IUCD in situ:

 There is no evidence at all that pregnancy is more likely than usual to result in an infant with congenital malformations if IUD s including copper devices are left in situ.  Thus the IUD need not be removed for fear of congenital malformations in the foetus.  But it should be removed, as an ongoing pregnancy with an IUD in situ has more chance of getting aborted or going into premature labour.

Oral Contraceptive pills:

Pregnancy with OC pills :

There is no increased risk of malformations in the babies of women who become pregnanty while taking OC pills.  If the woman desires to continue pregnancy, she should be reassured and a pregnancy termination should not be advised. 

 Quite often it is seen that when a pregnancy test is shown as weakly positive and there is an ongoing pregnancy, it may become strongly positive the next week.  While the patient is waiting for the matter to be settled, it is preferable to stop the pill and use some other method of contraception.

Breakthrough bleeding on OC pills:

Breakthrough bleeding is usually due to low oestrogen content in OC’s.  It may stop with continued use.  If it is bothersome to the patient, she could take 2 pills a day for 2-3 days after which she can continue with her old dose.  As an alternative, she can be given 0.02 mg /day of ethynyl estradiol(2 tablets of Linoral 0.01mg) for 2 or 3 days in addition for 7 days along with the pill.  From the next cycle onwards, she should be put on pills containing higher (0.05mg) dose of oestrogen (e.g: Ovral,Duoluton,Mala N,Lyndiol) This may be continued for at least 2 or 3 cycles.

 Weight gain after continued use of OC pills:

 The oestrogen in OC pills may cause oedema and progesterone may cause increase of tissue and fat due to anabolic effects.  Triphasic pills (Triquilar) , pills containing Desogestrel (Femilon,Novelon) may help in restricting weight gain due to their lower androgenic and anabolic effects.

OC pills & breast tenderness.

 Progestogen content of OC’s actually reduces the risk of cancer. The patient should be informed that by taking OC pills she is actually protecting herself from breast cancer.  The pain caused by the oestrogen in the OC’s pass off with continued use and wearing tight braissiers. The author has found pills containing VitaminE in the dose of 600mg /day useful in cases of mastalgia.

Headache & OC pills:

 Ovral-L contains a dose of 0.15mg Norgestrel as the progestin component.  Migraine is caused by the oestrogenic component of OC-pills. Changing to a pill containing higher progestogenic content may counter this effect.  Changing over to Primovlar,Ovral or Duoluton containing 0.25mg of Norgestrel may help.  If the symptom does not abate, the pill may have to be stopped.

Ccontraindications to the use of OC-pills:

 OC pills should not be used in patients with Thromboembolism,Cerebrovascular accident, liver adenoma. Gallbladder disease, cholestatic jaundice during pregnancy, focal migraine, malignancy of the breast or genital tract, or if surgery is contemplated within 4 weeks. Hypertension,diabetes,Epilepsy,obesity,H/O past liver disease, recent history of depression,sickle cell disease, hyperlipidemia, age over 45, smoking above 35 years of age are relative contraindications.

Injectable contraception:.

 For women who do not accept oral contraceptives or IUDs, there are injectable contraceptives available in the market.  They contain progestogens.  The two types of progestogens only injectable contraceptives which have been well tried are Depot medroxy progesterone acetate (DMPA) and Norethisterone enanthate(NET-EN or Noristerat). 150mg NET-EN injection given every 2 months is an effective regimen.  WHO has also recommended the dosage schedule of 200mg NET EN every 60 days for 6 months.  It has to be given in the first 5-7 days of the menstrual cycle.  It has no bad estrogenic side effects and does not inhibit lactation.  The most common side effects of the drug are irregular menstrual bleeding, spotting as well as temporary stoppage of periods.  For women using it for short periods, these irregularities may not be bothersome.  Proper counselling before administration can be helpful.  Irregular and heavy bleeding can be managed with 1.25-2.5mg conjugated estrogen for 7-21 days.  Use of Oral contraceptives in these cases is discouraged.

Emergency contraception:

 A combination of ethinyl estradiol 0.1mg with 1mg of dl-Norgestrel repeated after 12 hours(i.e Ovral 2 tablets stat and after 12 hours) starting within 72 hours of coitus has a failue rate of only 0.16% Antiemetics may be supplimented to prevent nausea.  If high dose pills are not available the low dose pills containg 0.03mg Ethinyl estradiol and 0.15mg l-Norgestrel (MalaD or Ovral-L) can be used.(4tablets stat and after 12 hours)  In case of failure, there is no risk of teratogenicity to the fetus. 

If the woman presents after 72 hours, IUD insertion is an effective method.  IUD’s inserted within 5-7 days of unprotected intercourse has been found useful.  Due to the higher chance of pelvic infection, it should be used cautiously in women with multiple partners or victims of rape,

Contraception for the woman with Diabetes:

Low dose OCs : Low dose oral contraceptives are safe in women with diabetes.. Compliance with insulin therapy and frequent medical evaluation are important. As virtually all currently marketed oral contraceptives contain a low-dose estrogen (0.030 to 0.040 mg), particular attention should be paid to selecting the lowest progestin dose with the least androgenicity, such as the monophasic NET preparations containing 0.50 mg or less or triphasic LNG preparations (0.075 to 0.125 mg). Before initiating oral contraceptive therapy, baseline monitoring of weight, blood pressure, glucose control (e.g., review of home glucose monitoring, postprandial glucose, glycosylated hemoglobin levels), and fasting lipids is recommended. After the first cycle of oral contraceptive use and every 3 to 4 months thereafter, weight and blood pressure must be monitored along with glycemic control (postprandial glucose and glycosylated hemoglobin levels). Because diabetic patients tend to exhibit elevated serum triglycerides, which may be exacerbated by an estrogen dominant oral contraceptive, a follow-up measurement of serum lipids at 3 to 6 months may be performed. Thereafter, unless indicated, lipid levels can be obtained annually. Along with encouraging good glycemic control via diet and medical therapy, the importance of maintaining ideal body weight and engaging in a daily moderate exercise program should be stressed and discussed at each visit.

Progeterone only pill:Progesterone only minipills or progesterone depot preparations are other alternatives.

IUCD: Physicians are skeptic about IUD insertion in the diabetic woman due to their increased susceptibility for pelvic inflammatory disease. Proper aseptic techniques and the use of antibiotics during insertion can minimise this risk.. The greatest risk for pelvic inflammatory disease associated with IUD use occurs during the first 4 months after insertion. Antibiotic prophylaxis at time of insertion may be of benefit in reducing postinsertion infection and probably should be considered. Recommended antibiotics include doxycycline (200 mg prior to insertion and 100 mg 12 hours later), erythromycin (500 mg prior to insertion and again 6 hours later),  or azithromycin (500 mg prior to insertion).  The procedure should be delayed if bacterial vaginitis/cervicitis or pelvic tenderness is detected until a cause is established and the symptoms resolved. A 4 to 6 weeks postinsertion examination allows the detection of infection and identifies explusions.