Modern methods of contraception. Theory of aseptic inflammation. Physiological contraceptive methods

About 6 to 8 weeks after giving birth, most women can start sexual life, which means that you should think about protection from pregnancy. During this period, there are certain features of the physiology and anatomy of a young mother, which should be taken into account when choosing a method of contraception.

The selection of a method of protection after childbirth should be taken very seriously. After all, pregnancy can occur even before the next menstruation, turn out to be a complete surprise for a young mother and lead to serious emotional and physical stress. And for the full recovery of the woman's body and the normal bearing of the next pregnancy, it is recommended to wait at least two years.

Lactational amenorrhea method

Within 3-4 weeks after childbirth, the uterus returns to its previous size. The tissues of the vagina and perineum after spontaneous childbirth are restored somewhat longer than after childbirth by caesarean section, and the condition of the mucous membrane depends on the level of female sex hormones. In lactating women, the pituitary gland produces a large amount of prolactin, which suppresses the maturation of follicles and the production of female hormones in the ovaries, so the level of estrogen is low, ovulation does not occur (lactational anovulation), and, accordingly, menstruation is absent (lactational amenorrhea). Therefore, theoretically, the probability of pregnancy in a nursing young mother is very low.

With active breastfeeding, you can rely on lactational anovulation until the child reaches the age of 4-5 months, but only if certain rules. The effectiveness of the method of lactational anovulation / amenorrhea is about 98%, only if a woman feeds “on demand”, including at night, that is, daytime breaks are no more than 3-3.5 hours, and one night break- up to 5-6 hours. If the number of feedings decreases for any reason (medical or social), the effectiveness of the method decreases and becomes unpredictable, that is, it can no longer be relied upon. If subsequently the number of feedings increased again, then the effectiveness of the method remains doubtful and a doctor's consultation is required to resolve the issue of the possibility of further use of lactation as a contraceptive.

You should also pay attention to spotting from the genital tract. Postpartum discharge (lochia) can last up to 2 months. After this period, the resumption of spotting can be regarded as menstruation and, accordingly, the restoration (albeit possibly incomplete) of the woman's ability to conceive. In this case, you need to choose another method of contraception. All things considered, lactation is a temptingly simple and convenient form of contraception, but not entirely reliable.

As for non-nursing women, by the end of the postpartum period (6-8 weeks after birth), in the absence of the inhibitory effect of prolactin, they gradually restore the synthesis of female hormones and the process of maturation of follicles. Therefore, in young mothers who do not breastfeed at all or feed little (the child is on mixed feeding), the first menstruation begins two to three months after birth. Accordingly, at this time, their ability to conceive is restored, although, of course, the body's reserve for carrying the next pregnancy is not yet restored.

Thus, the approach to contraception in actively breastfeeding mothers differs from women who breastfeed irregularly or not at all.

Contraceptives used in the postpartum period and during breastfeeding must meet certain requirements. Above all, they must be highly efficient and reliable. In addition, when choosing a method of protection for lactating women, it is necessary to take into account the effect of drugs on lactation. The selection of funds for them is determined by the age of the child and the activity of lactation (the child is completely breastfed or mixed-fed). In women who do not breastfeed at all, contraception has no specific features compared to healthy women of the same age. It is important to note the time when it is necessary to start contraception when resuming sexual activity after childbirth. In the absence of lactation or with mixed feeding, contraception will be required immediately at the onset of sexual activity.

Barrier contraception

Barrier contraception is a group of drugs whose action is based on the mechanical impossibility of penetration of spermatozoa into the cervix. This is primarily a condom that has no contraindications for use (except for individual intolerance), is highly effective when used correctly, protects against sexually transmitted diseases, has no effect on breast milk, can be used immediately after childbirth, but has their shortcomings. The main disadvantage of condoms is that their use is necessary immediately before sexual intercourse and requires a certain discipline and strict adherence to instructions for use.

Barrier methods also include cervical caps and vaginal diaphragms, which are practically not used in our country.

A common method of contraception that can be used in the postpartum period and is also classified as a barrier is spermicidal preparations. They come in a variety of forms - suppositories, vaginal creams, sponges, etc. Active ingredient in these preparations is benzalkonium chloride (PHARMATEX) or nonoxynol (PATENTEX-OVAL), they inactivate spermatozoa in the vagina and thus prevent the penetration of spermatozoa into the uterus, they are practically not absorbed into the blood and do not penetrate into milk. These funds can be more recommended for nursing mothers. This is due to two factors. Firstly, their effectiveness is not very high: about 25-30 pregnancies per 100 women occur per year (Pearl index - the number of pregnancies per 100 women per year), but given that a woman's fertility is somewhat reduced during lactation, this is enough to protect against unwanted pregnancy. Secondly, when using spermicides, foam is formed, which provides additional comfort with dry mucous membranes, which is often observed in women after childbirth.

A contraindication for the use of these drugs is individual intolerance and allergic reactions, acute inflammatory diseases of the genital organs. It should be borne in mind that spermicidal agents do not protect against sexually transmitted diseases. The disadvantage of spermicides is that they must be used some time before sexual intercourse, strictly following the instructions for use.

Intrauterine contraceptives

After giving birth, women can start using intrauterine contraceptives - spirals (IUDs). The mechanism of action is to increase contractile activity uterus and excessive peristalsis of the fallopian tubes due to the presence of a foreign body. This leads to premature entry of the egg into the uterus, so fertilization does not occur. Also foreign body causes certain changes in the innermost lining of the uterus, the so-called aseptic inflammation, so the fertilized egg is not able to implant.

The IUD is an inert plastic carrier, most often T-shaped, 3–3.5–4 cm in size, wrapped in metal (most often copper) wire. 2 nylon threads are attached to the plastic rod - antennae, which are needed to remove the IUD.

The IUD is inserted by the doctor into the uterine cavity on the 2nd-3rd day of menstruation, while the “whiskers” of the spiral remain in the vagina (strong thin threads that indicate that the IUD is in the uterus and which can subsequently be used to remove it). After childbirth, it is recommended to insert the IUD after 6 months or during the first menstruation, and before that, use barrier contraception or the method of lactational amenorrhea. The IUD is also removed by a doctor, preferably also during menstruation, no later than 3-5 years after the introduction.

The method has undeniable advantages - after installing the IUD, you can not worry about contraception and unplanned pregnancy for several years (different manufacturers recommend replacing the IUD in the interval of 3-5 years). After the establishment of the IUD, the effect occurs immediately, the effectiveness of the method is very high: the Pearl index is 0.9-2.0 (that is, 1-2 women out of 100 can become pregnant during the year when using the IUD), the drug is not absorbed into the blood and does not have no effect on breast milk. But there are also a number of serious shortcomings.

The main problem that is associated with the use of IUDs is a higher level of inflammatory diseases of the genital organs. This complication, in fact, is associated with the mechanism of action of the contraceptive, that is, with the presence of a foreign body that facilitates the penetration of infection into the uterus (infection along the tendrils of the spiral located in the vagina can rise into the uterine cavity). Against the background of the use of the IUD, menstruation may become more painful and plentiful. Due to changes in fallopian tube motility, women using IUDs are 4 times more likely to have ectopic pregnancies. This occurs mainly after the removal of the helix, in rare cases An ectopic pregnancy can also occur when using the IUD, since the embryo cannot attach to the uterus. It is noted that the longer the IUD is used (more than 3 years), the higher the risk ectopic pregnancy, due to the fact that cilia disappear in the mucous membrane of the fallopian tubes, pushing the fertilized egg into the uterus. In addition, in the presence of cicatricial deformity of the cervix (as a result of its rupture during childbirth), there is a high probability of expulsion (falling out) of the spiral during menstruation.

With this in mind, the method has contraindications and limitations. First of all, the use of IUDs is contraindicated in chronic inflammatory diseases of the genital organs. Relative contraindication is the presence of an ectopic pregnancy in the past. According to WHO recommendations, this method of contraception is more suitable for older women (after 35-40 years) who have children. Before using this method, it is necessary to consult a doctor, examine for inflammatory diseases of the genital organs, and ultrasound of the pelvic organs. Against the background of the use of the IUD, you should visit the gynecologist once every 6-9 months.

Hormonal contraception

Hormonal contraception is the most reliable, safe and convenient method of protection. The Pearl Index is 0.01-0.05, the highest for reversible contraceptive methods. The reversibility of contraception means a complete independent restoration of the ability to conceive and bear a child after stopping the use of one or another method of contraception.

Hormonal contraceptives are divided into several main groups. The most widely used are the combined estrogen-progestin oral contraceptives. These drugs contain synthetic analogues of two female hormones that are produced in the body in the first and second phases. menstrual cycle(estrogens and gestagens).

A group of drugs that contain only a progestogen component similar to the female hormone progesterone is called mini-pills (CHAROSETTA, EXLUTON, MICROLUT).

There are also purely progestogen preparations of prolonged action. Among them there are injections (DEPO-PROVERA) and subcutaneous capsules (NORPLANT), but due to a large number side effects, these drugs are not currently used in developed countries. Of this group of drugs, you should pay attention only to the intrauterine hormonal system MIRENA. MIRENA is a T-shaped intrauterine device, on the vertical part of which there is a cylinder containing levonorgestrel (a hormonal drug, an analogue of the hormone progesterone). Due to the low content of hormones and absorption at the level of the uterus, this drug has minimal amount side effects, and due to the combination of hormonal and intrauterine contraceptive action - high efficiency (Pearl index less than 0.1).

New generations of parenteral combined funds(Patch EVRA, ring NOVO-RING). These funds essentially do not differ from the combined hormonal pills, except for the way the substance enters the body - absorption active substance occurs through the skin (patch) or through the vaginal mucosa (ring). With such methods, the achievement of a contraceptive effect is carried out by lower doses of drugs. In general, these drugs have all the same indications and contraindications as the combined tablets.

The mechanism of action of hormonal contraceptives has been studied in great detail and differs somewhat for combined and purely gestagenic preparations. Both groups of drugs increase the viscosity of the mucus of the cervical canal, which prevents the penetration of sperm, slow down the peristalsis of the fallopian tubes and the passage of the egg through them, contribute to a change in the structure and thinning of the inner lining of the uterus. This leads to the fact that the egg cannot meet with the sperm in the fallopian tube at the moment when it is ready for fertilization. Further, if fertilization did occur, implantation of the egg into the uterus is impossible due to a sharp thinning and change in the structure of the uterine mucosa. Combined contraceptives, in addition, to a greater extent than purely gestagenic ones, have a central effect - they act on the regulatory centers of the brain and prevent their stimulating effect on the ovaries. Without receiving any signals, the synthesis of female hormones in the ovaries is inhibited, the dominant follicle (the one from which the egg is released after ovulation) does not mature, and ovulation does not occur.

Thus, the contraceptive reliability of pure progestogen preparations is slightly lower than the combined ones, but still it is less than 1 per 100 women per year (Pearl index less than 1).

First of all, it should be noted that, since the estrogen component of combined drugs reduces the production of breast milk, this group of drugs is not recommended for lactating women. Their use is possible only for mothers whose children are on artificial feeding. Purely gestagenic mini-pills and the Mirena spiral do not have such an effect, and gestagens enter the milk in an extremely small amount, which cannot have any effect on the child's body, so these drugs can be recommended to nursing mothers.

You can start using hormonal contraceptives only after consulting a doctor and the necessary examination, which allows you to identify contraindications for the use of hormonal contraceptives in a woman, as well as choose the most suitable drug. Against the background of the use of mini-pills, a very common side effect is scanty spotting from the genital tract, not associated with menstruation. This side effect is much less common in breastfeeding women than in non-breastfeeding women. This side effect does not require discontinuation of the drug.

Nursing mothers who use the lactational anovulation method are recommended mini-pills, and you can start taking it from any day, but only as long as all the feeding rules are followed and the lactational amenorrhea method is considered reliable. For maximum confidence in the contraceptive effect, it is advisable to start taking no later than 6-8 weeks after birth. If the number of feedings has decreased and lactation is no longer a completely reliable method of contraception, then barrier contraception should be used until menstruation begins, and then mini-pills can be started from the first day of menstruation.

Tablets are taken one per day, strictly at the same time, without interruptions, the next package should be started immediately after the end of the previous one. Accuracy in taking mini-pills is very important to ensure contraceptive effect, because the duration of one pill is exactly 24 hours. Young mothers who have a mixed-fed baby should start taking a mini-pill either 3-4 weeks after birth or later, having already waited for the first menstruation, and before that, use barrier contraception. You can continue taking it until the complete cessation of lactation, or longer - with good tolerability of the drug. Against the background of the use of hormonal contraception, it is necessary to visit a gynecologist at least once a year. After the abolition of hormonal contraception, the ability to conceive is restored mainly in the first or second menstrual cycle.

In the postpartum period, combined hormonal contraceptives are recommended for non-nursing mothers, and they can be taken from the first day of the first menstruation, and before that, barrier contraceptives should be used. The drugs are taken according to the scheme 21-7, that is, for 21 days you should take the medicine one tablet a day, at the same time, then a break for 7 days - at this time menstruation passes, and regardless of its end, the drug is taken.

Before using any hormonal contraceptives, you should consult your doctor to identify contraindications for use. These drugs should not be used in severe liver disease, malignant tumors of any localization, hypertension and coronary heart disease, in the presence of severe metabolic disorders, including obesity, strokes and thrombophlebitis (including in the past) and in some other conditions. With this in mind, these drugs can only be prescribed by a doctor.

The main side effects are mainly weight gain, but, fortunately, the drugs of the latest generations (YARINA, JES, CHAROSETTA) as well as parenterals(MIRENA, EVRA, NOVO-RING) do not have them. There may be a decrease in libido, engorgement of the mammary glands, rarely - mood changes. Basically, all side effects disappear by the 2nd or 3rd cycle of drug use.

irreversible methods of contraception

Separately, it should be briefly said about irreversible methods of contraception. For men, this is a vasectomy, that is, ligation of the vas deferens, which prevents sperm from entering the ejaculate, with the complete preservation of hormonal and sexual function. For women, this is a “ligation” of the fallopian tubes, also with complete preservation of hormonal and sexual functions. The operation is performed laparoscopically (that is, through small incisions on the skin, no more than 1 cm), under anesthesia, while a section of the tube is excised or cauterized and the meeting of the egg and sperm becomes impossible. The irreversibility of the methods implies that in the future, pregnancy in a natural way will be impossible, therefore, serious and balanced reasons are required for its use.

In conclusion, I would like to recommend young mothers to be attentive to their body after the birth of a baby, because adequate and complete recovery after childbirth is the key to your reproductive health and the birth of healthy children in the future.

Contraception(from Latin contraceptio - against conception) - protection from conception.

In the modern market of medical and pharmaceutical services, there is great amount methods and means to prevent unwanted pregnancy or contraception.

They began to think about contraception back in primitive society, which led to the creation of many unique methods of protection.

In ancient Africa, for example, interrupted sexual intercourse and the introduction of a “cocoon” of various plant substances into the vagina were used as a means of contraception.

From the works of Aristotle it is known that in ancient Greece they used various oils and incense to make it difficult for sperm to enter the uterus. In addition, men rubbed the penis with juniper berries, and women drank an infusion of copper sulphate.

There are several types of contraception:

• mechanical with the use of condoms, which is also a means of protection against sexually transmitted diseases and HIV;
• interrupted sexual intercourse is one of the common methods of contraception, but it disrupts the physiology of sexual intercourse and negatively affects the female and male orgasm;
• surgical methods of sterilization of men and women are not often used, which is associated with the impossibility in most cases after surgery to restore reproductive function;
• intrauterine contraception using intrauterine devices - foreign bodies for the body that keep the uterus in good shape and prevent a fertilized egg from attaching to it;
• chemical, which is based on acidifying the vaginal environment with the help of special suppositories, tablets, creams that have a detrimental effect on spermatozoa, this group includes drugs Contraceptin-T, Pharmatex, Benatex, Patentex-oval;
• hormonal, based on the introduction into the body of a woman of certain sex hormones that protect against pregnancy for the period of taking the pills, the action of the Evra patch (7 days), the NovaRing vaginal ring (3 weeks) or the Mirena intrauterine system (5 years); This group includes the method emergency contraception, developed for women who have been raped, using Postinor or Escapelle tablets;
• physiological, taking into account the phases of the woman's menstrual cycle, which is also called natural family planning methods.

Mechanical methods of contraception

The condom was one of the first contraceptives in the world. Historians claim that the first condom was leather and was worn by Pharaoh Tutankhamun. This can be seen by visiting the National Museum in Cairo. Then bull bladders, caecum of sheep went into action. Moreover, it recently turned out that the ancient Romans also used condoms, who made them from resin.

In 1564, when almost the entire adult population of Italy was suffering from syphilis, the eminent physician and anatomist Gabriel Fallopius proposed the use of a canvas bag to protect against this vile disease. It was proposed to impregnate the bag with medicines and inorganic salts.

It is believed that the word "condom" comes from the name of the English doctor Condom, the court doctor of the English king Charles II (1630-1685). The king ordered his doctor to come up with something to protect against syphilis.

The doctor suggested using oil-lubricated sheep intestine caps. The invention of the doctor came to court, and soon the entire aristocracy used these means of contraception and protection against love ailments. True, they were used several times, so the diseases continued to spread. But illegitimate children began to be born less.

About what are the rules for buying and using condoms, written in hundreds of booklets distributed by volunteers and employees of various institutions and organizations. It remains to be recalled that the condom is a means of protection not only from accidental pregnancy, but also from sexually transmitted infections (STIs).

Interrupted act and sterilization

Sterilization consists of tubal ligation in women or surgical cutting of the seminal ducts in men.

It is one of the contraceptive methods currently used by over 170 million couples in over 100 countries. As scientists have established, British men decide on sterilization more often than others. Every year in England, 64,000 male sterilizations and 47,000 female sterilizations are performed. The UK is one of four countries, along with New Zealand, the Netherlands and Bhutan, in which the number of sterilized men exceeds the number of women sterilized.

In Russia, sterilization has become an increasingly popular solution to the problem of contraception in recent years. Since 1990, the use of sterilization in women with their consent and for medical reasons has been legally allowed, and since 1993 - in both men and women.

In accordance with article 37 of the Fundamentals of Legislation Russian Federation on protecting the health of citizens: “Medical sterilization as a method of contraception can only be carried out upon a written application of a citizen who is at least 35 years old or has at least two children, and if there are medical indications and the consent of the citizen, regardless of age and the presence of children.”

When choosing this method, it must be remembered that this method is irreversible and after the operation the person loses the ability to have children forever. Therefore, this method is acceptable only for those who are absolutely sure that they will no longer want to have children. At the slightest doubt, it is better to postpone the decision and use other methods of contraception at this time.

intrauterine contraception

In 1960, the American Jack Lipps developed the so-called "Lipps Loop", the uniqueness of which was that for the first time elastic materials were used for the manufacture of the IUD, which made it possible to minimize trauma to the woman during the installation of the spiral. It was from this moment that spirals became widespread.

An IUD is a small, flexible device inserted into the uterine cavity at long time to prevent pregnancy. There are two types of IUDs: non-drug and medication. The latter are made of plastic and contain medicinal product, which is released from them gradually in small quantities (copper or progestin). Intrauterine devices are produced in a very diverse form (T-shaped, in the form of a ring, spirals, etc.).

Scientists still have not exactly established how the IUD protects against unwanted pregnancy, so there are many hypotheses:

• Hypothesis of the abortive effect of the IUD. Under the influence of the IUD, the endometrium is traumatized, the release of prostaglandins, the tone of the muscles of the uterus increases, which leads to the expulsion of the embryo in the early stages of implantation.
• Hypothesis of accelerated peristalsis. The IUD increases the contractions of the fallopian tubes and uterus, so the fertilized egg enters the uterus prematurely. The trophoblast (embryo) is still defective, the endometrium (uterine mucosa) is not prepared to receive a fertilized egg, as a result of which implantation is impossible.
• Hypothesis of aseptic inflammation. The IUD as a foreign body causes leukocyte infiltration of the endometrium. Emerging inflammatory changes endometrium interfere with implantation and further development embryo.
• Hypothesis of spermatotoxic action. Leukocyte infiltration is accompanied by an increase in the number of macrophages that carry out phagocytosis of spermatozoa. The addition of copper and silver to the IUD enhances the spermatotoxic effect.
• The hypothesis of enzymatic (enzymatic) disorders in the endometrium. This theory is based on the fact that IUDs cause a change in the content of enzymes in the endometrium, which has an adverse effect on the implantation process.

Chemical contraception

Even in the recent past, such a method of contraception as douching was common in the USSR - washing the vagina from Esmarch's mug (a large rubber "heater") immediately after intercourse large quantity liquid acidified with a weak solution of potassium permanganate or acetic acid.

method chemical contraception in the absence of anything else at hand, there may be a slice of lemon, cut off in the same way as for tea and inserted into the vagina before intercourse. When using this method, it must be remembered that after the end of sexual intercourse, the remains of the lemon slice must be removed from the vagina so that the mucous membrane does not burn.

The mechanism of the contraceptive action of spermicides (or chemical contraceptives) is based on the ability of the active ingredient in their composition to destroy spermatozoa within a few seconds (no more than 60). Such a strict requirement for a time interval is explained by the ability of spermatozoa to penetrate into the cervical canal already a few seconds after ejaculation, and after 90 seconds - to reach the fallopian tubes.

Spermicidal substances are available in the following forms: jellies, foams, melting candles, foaming candles, foaming tablets, soluble films - all of them are applied only topically, i.e. inserted into the vagina before intercourse.

In addition to being a contraceptive, many spermicides protect against sexually transmitted infections, as they kill all microorganisms in their path, but this has only been studied in vitro. There were no volunteers knowingly willing to use spermicide during sexual intercourse with an HIV-infected partner. Therefore, doctors insist that better protection from STIs than a condom - no.

Hormonal contraception is the most widespread in the world today. In ancient times, it was not used, because they did not even suspect the existence of hormones.

A serious turning point in the development of contraception was the discovery of sex hormones - estrogen in 1929 and progesterone in 1934. However, it took scientists more than a dozen years to clarify the role of hormones in the functioning of the female body, to understand how they affect pregnancy and learn how to get them artificially.

All this led to the creation in 1960 of the first hormonal contraceptive pills, which made a real revolution in contraception. Since then, contraceptive preparations have been constantly improved, the dose of hormones contained in them has decreased, and combined contraceptives containing several types of hormones have appeared.

Gradually birth control pills became more and more effective, the number of side effects decreased, the number of additional benefits increased. And today, oral contraceptives are often prescribed to women even for medicinal purposes, because they not only help prevent unwanted pregnancy, but also have a therapeutic effect on the body.

It is necessary, for example, for various hormonal disorders, irregular or heavy menstruation. Many birth control pills make menstruation so short that it generally ceases to cause discomfort to a woman.

Hormonal contraceptives

Modern oral (taken by mouth) contraceptives are divided into three groups: microdosed, low-dosed and mini-dose,

Microdosed combined oral contraceptives (COCs), predominantly monophasic, contain the most minimal amount of estrogen (20 μg of ethinyl estradiol) in combination with progesterone, are shown to young girls who first start using hormonal contraception. Among the COCs of this group, Minisiston 20 fem, Logest, Lindenette, Mercilon and Novinet can be distinguished.

Low-dose COCs contain the estrogenic component ethinylestradiol at a dose of 30-35 mcg. These drugs provide reliable contraception, control of the menstrual cycle, good tolerance and for the most part have a therapeutic effect. Low-dose contraceptives, such as Femoden, Microgynon, Triquilar, Janine, Yarina, etc., are recommended for young and middle-aged women.

Mini-pill is a type of oral contraceptive alternative to COCs. Mini-pills contain only one component - progestin (a synthetic analogue of the hormone progesterone, which is produced in the ovaries), while combined oral contraceptives consist of synthetic analogues of two female sex hormones - estrogen and progesterone.

In this regard, purely progestin preparations are considered less reliable than COCs. If there are contraindications for the use of COCs, it is mini-pills that can become an indispensable method of protection. The contraceptive effect of the minipill is based on a change in the quality of the cervical mucus, which becomes thicker and forms an impenetrable barrier to spermatozoa.

Under the influence of the mini-pili, the uterine mucosa changes, and the embryo is not able to attach to it. In addition, there is a slowdown in the peristalsis (movement) of the fallopian tubes, through which the egg enters the uterine cavity.

Thus, mini-pills have a less pronounced contraceptive effect, unlike COCs - 5 pregnancies per 100 (95%) women during the year of use (COC efficiency - 99%). Mini-pills include drugs: Exluton, Microlut, Charozetta.

emergency contraception

Its essence is to prevent the fertilized egg from attaching to the wall of the uterus and continue its development. This is a kind of "micro-abortion", since a real, but only a very small, miscarriage occurs in the woman's body.

Emergency contraception is used if:

• committed rape;
• unprotected intercourse has occurred;
• interrupted sexual intercourse was incorrectly performed;
• the condom broke during intercourse;
• the diaphragm was removed from the vagina early;
• other similar situations.

Another remedy is Escapelle. This is an exclusive new product for emergency contraception. Recommended for use within 96 hours of unprotected sex. The earlier the pill is taken, the more effective its action.

It must be remembered that in no case should you use emergency contraceptives regularly. It is better not to take them ever, because they were created primarily to help women who suffered from rape.

In recent years, contraceptives in the form of patches or transdermal therapeutic agents have become increasingly common. Such a tool is the Evra patch, which combines the effectiveness of oral contraceptives and the convenience of the patch.

It refers to prolonged (long-acting) combined methods of hormonal contraception. Evra ensures uniform supply of hormones; daily 150 mcg of norelgestromin and 20 mcg of ethinyl estradiol enter the bloodstream. The action of these hormones is to prevent ovulation by reducing the gonadotropic function of the pituitary gland and suppressing the development of the follicle.

During one menstrual cycle, 3 Evra patches are used, each of which is applied for 7 days. Evra is glued on dry clean skin(in the area of ​​the buttocks, abdomen, outer surface of the upper part of the shoulder or the upper half of the torso).

Contraceptive patch Evra refers to microdosed contraceptives that combine efficiency and maximum safety in use. The absence of the "forgetting effect" makes the Evra contraceptive patch one of the most effective methods of contraception.

The effectiveness of the transdermal contraceptive system Evra does not depend on functional state gastrointestinal tract. Evra transdermal patch is very simple and comfortable to use, it is securely attached to the skin, does not peel off either during water procedures or under the influence of the sun. In addition, the Evra patch is very convenient for visual control.

The action of vaginal hormone rings NuvaRing and Mirena intrauterine systems are based on the gradual release of sex hormones from them, which have a contraceptive effect. The NovaRing ring is inserted into the vagina by the woman herself for 3 weeks each menstrual cycle, and then removed on her own. The Mirena system is inserted into the uterine cavity by a gynecologist for a period of five years.

Physiological contraceptive methods

In the traditions of the African Nandi people, as well as among the South American Indians, there is a prescription - in order to avoid conception, women refrain from sexual intercourse on certain days of the menstrual cycle - thus, the calendar method was known for many centuries BC.

The method of natural family planning or calendar is based on the studies of Ogino-Knaus, the essence of which is to calculate the days during the menstrual cycle in which conception rarely or does not occur at all. Ovulation - the release of an egg from the ovary usually occurs on the 14th day of a 28-day cycle.

Considering that the viability of the egg cell lasts up to 5 days, and the spermatozoon - up to 3 days, the days of potential fertility are considered to be the 9-17th, i.e. the very middle of the menstrual cycle, which is considered from the first day of one menstruation to the first day of the next menstruation (Fig. 6).

Rice. 6. Scheme of calendar, temperature and cervical methods of contraception.

With the temperature method, it is necessary to measure the basal body temperature (temperature in the rectum) daily. It is measured in the morning before a woman gets out of bed to catch the time of ovulation.

The temperature in the rectum at the beginning of the menstrual cycle is 36.2-36.7 ° C, and at the time of ovulation it rises sharply by a whole degree - up to 37.0-37.2 ° C, after which it gradually decreases by the beginning of the next menstruation. Sexual life should be abstained from the day the menstruation ends and for another 2-4 days after the temperature rises.

Sometimes there is no jump during the menstrual cycle basal body temperature what is called an anovulatory cycle. This means that ovulation does not occur and pregnancy cannot occur in principle. Method basal measurement temperature, therefore, is necessarily used as a diagnostic tool in identifying the causes of infertility.

The ovulation method, or the Billings method (was developed in 1960 by the Australian spouses Evelyn and John Billings), is based on changing the mucous secretions from the vagina, which can be used to set the days when the probability of conception is high. This mucus is formed by the glands of the cervix, so the method is also called cervical (cervical).

The appearance of whitish or cloudy sticky mucus in the vagina indicates the onset of these days. 1-2 days before ovulation, the secretion of mucus increases, the ion becomes more transparent and viscous, and the consistency is very similar to egg white. It is believed that sexual intercourse is "safe" 4 days after the appearance of such mucus, when it becomes cloudy again and until the end of the next menstruation.

In general, the effectiveness of physiological methods leaves much to be desired. Scientists have created several devices for detecting ovulation at home by the release of sex hormones into the urine; Perhaps, over time, the use of such devices will improve the effectiveness of the physiological method of contraception, but there has not yet been a truly scientific research in this area.

A highly educated, civilized woman can always, with the help of a gynecologist, choose for herself suitable way contraception and plan for the birth of future children without resorting to abortion.

The body of a woman is arranged in an amazing way, it is able to organically rebuild work in connection with the menstrual cycle, pregnancy and lactation. internal organs and systems (nervous, cardiovascular, hematopoietic, endocrine, etc.), change metabolism. This makes it possible to conceive, endure, give birth, raise offspring and be ready to become pregnant again.

During the period of breastfeeding, a gradual restoration of the reproductive function of a woman occurs. At this time, the onset of a new pregnancy is highly undesirable. In a fragile mother's body, disruptions in the functioning of systems can occur, her body has a double burden of feeding and caring for the baby and carrying a new pregnancy. In addition, a pregnancy that occurs immediately after childbirth most often cannot proceed normally, it can cause a deterioration in the health of a woman, a delay in the development of the fetus and the birth of a child with any pathology.

Very often, after the onset of an unwanted pregnancy, a woman resorts to an abortion. But abortion is not a harmless, trifling operation. First of all, it is a gross injury to the body. As a result of an abortion, a woman undergoes drastic changes in the activities of such endocrine glands like ovaries, adrenals, pituitary. Painful impulses with nerve endings uterus and other organs of the small pelvis enter the brain, which is fraught with disturbances in the regulation of metabolism, reproductive function, and the menstrual cycle. These changes may not occur immediately after an abortion. Therefore, the idea of ​​the harmlessness of this intervention is widespread.

Often, health problems arise against the background of an infectious disease, hypothermia or prolonged exposure to the sun, after stress or physical injury. The violations that have arisen in this case are most often associated with the named, provoking conditions, and the root cause - abortion - is forgotten. Serious pathological changes in connection with abortion occur directly in reproductive organs. First of all, inflammatory diseases of the uterus, ovaries, fallopian tubes develop, which then pursue a woman for a long time, if not all her life. The inner lining of the uterine wall is damaged, which leads during subsequent pregnancy to disruption of the formation of the placenta - the organ that connects the fetus with maternal organism. Cicatricial changes occur in the cervix. The fallopian tubes become difficult to pass, as a result of which fertilization is difficult or even impossible. According to statistics in our country, there are 200 abortions for every 100 births. Compared to Western countries, this terrible figure in Russia is six times higher.

Modern methods of contraception

In the 21st century, there has been an active development of birth control programs. The choice of a method of protection against unwanted pregnancy is changing with the advent of more and more effective and safe methods for a woman's health, among which today one of the most advanced is oral hormonal contraception with combined estrogen - progestogen preparations.

Also a very popular method at the present stage of development of contraception is the use of intrauterine contraceptives (IUDs). Naturally, the emergence of the above highly effective methods has gradually made the use of condoms, diaphragms and withdrawal less and less popular in most countries. However, the relevance of condoms is not reduced because they protect to a certain extent from sexually transmitted diseases, in particular from AIDS.

The methods of contraception used are very diverse, and are divided into two large groups: traditional and modern. To traditional methods contraceptives include: Physiological (biological)- based on knowledge of a woman's fertile period (the period when she is able to become pregnant) and exclude sexual activity at this time. The main advantages of the method are that it is generally accessible, free, harmless to the woman's body.

But physiological methods of contraception have a very low degree of protection. (20-25 pregnancies per 100 women during the year) and sufficiently long periods of abstinence from sexual activity. Barrier- prevent the meeting of the sperm with the egg mechanically or with the help of chemicals. Barrier protection means are generally available, harmless, but have low contraceptive activity. (15-20 pregnancies per 100 women during the year) and should always be available.

Modern methods of contraception include:

Intrauterine devices - prevent implantation (attachment) of the fetal egg in the uterus, affect the mobility of spermatozoa and the egg. Their main advantage is high efficiency (0.5 pregnancies per 100 women during the year) and duration of validity. The disadvantages include the presence of contraindications and the fact that the insertion and removal of the IUD can only be carried out by a gynecologist.

Hormonal remedies- inhibit ovulation by acting on the endocrine glands. These methods of contraception have a very high degree of effectiveness. (0.05-0.5 pregnancies per 100 women during the year and with the right selection correct hormonal disorders. The main disadvantages of the use of hormonal drugs are the need for their selection by a gynecologist, the daily intake, the presence of contraindications, and if the wrong choice or overdose of drugs - side effects.

Surgical sterilizationI- Irreversible cessation of male or female reproductive function through surgery, during which the passage of the fallopian tubes in a woman or the vas deferens in a man is blocked, which prevents the sperm from meeting with the egg. This is the most effective method of contraception, but irreversible (it is impossible to restore fertility).

A novelty in recent years has been the use male hormonal contraception- taking hormonal drugs temporarily suppressing the formation of spermatozoa.

Male "spiral"- another of the new methods. The spiral is like a small folded umbrella. It is inserted through the head of the penis into the scrotum using a special tool. At the end of the spiral, for greater reliability, there is a gel that kills spermatozoa. This is a brief overview of contraceptives. None of the modern methods of preventing pregnancy is perfect. Each of the means has its own advantages and disadvantages. A series of articles on contraception will acquaint you with all currently existing methods of contraception, present indications and contraindications for each of them.

Ovulation (lat. ovum - egg), the release of a mature, fertile egg from the ovarian follicle into the abdominal cavity; stage of the menstrual cycle. Ovulation in women childbearing age occurs periodically, every 21-35 days.

There are reversible methods of contraception and irreversible.

After using an irreversible method of contraception, a woman no longer has the opportunity to become pregnant.

Our country occupies one of the leading places in abortion. And this is despite the fact that there are many types of contraception in the world. I think the reason is that little attention is paid to educating teenagers about this issue.

Both girls and boys need to be taught both the medical and psychological consequences of abortion during adolescence. Feel free to tell them about your contraceptive options.

Many parents believe that by talking about the rules of protection, they provoke their children to increased attention to sex.

In fact, all children at a certain age become interested in sexual matters.

And if at that moment they receive information from their own peers, then in consequence just such limited information can lead to an unwanted pregnancy.

Not teachers and not society, namely parents are responsible for the sexual illiteracy of their children. And in order for parents to be able to convey information in the right form to their children, they must, first of all, themselves be literate in matters of contraception.

Types of contraception:

Hormonal contraceptives:

oral contraception

This type of contraception is widely used throughout the world. He is very well studied. Modern drugs do not have serious side effects.

OC (oral contraception) is a highly effective and reversible method.

This method has perhaps one serious disadvantage.

In order to take pills, you need to be a fairly disciplined person, because. contraceptives should be taken regularly at the same time.

Contraceptive patch "Erva"

During the menstrual cycle, 3 patches are used. One per week. The patch must be changed on the same day of the week. One week break. At this time, the woman is menstruating.

The patch can be applied to the abdomen, buttocks, torso or arm. The effect of the drug does not depend on the place of application. The patch, like the oral contraceptive, suppresses ovulation. This method is also highly efficient and reversible.

Vaginal ring Novo-Ring

It's relative new method contraception. With this ring, hormones are injected directly into the vagina. Through the vagina, they are evenly absorbed into the blood throughout the day. The shape of the vagina allows you to securely fix the ring inside. It is flexible and elastic and adapts to the shape of the body, so the woman does not feel a foreign object.

Nova-Ring can be inserted and removed on its own, without a doctor. Each ring is used for one cycle only. During the menstrual cycle, it is set for three weeks, then removed and a break is taken for 7 days.

You need to insert and remove on the same day, at the same time. For example, if the installation was done on Monday at 7 am, then you also need to clean it on Monday at 7 am after 3 weeks.

Some women noted that the use of this contraceptive gives them additional pleasure during intercourse.

Mirena

This is a polyethylene T-shaped system, similar to a spiral. Mirena contains progestin, which is evenly released into the body throughout the day, preventing fertilization. This method of contraception is very effective and comparable to sterilization. This method is reversible. The term of use of one Mirena is very long up to 5 years.

After removal of the remedy, the recovery period of reproduction lasts from 6 to 12 months. If necessary, you can continue contraception after 5 years, you can install a new Mirena.

In addition to its contraceptive properties, Mirena also has some medicinal properties. It relieves painful menstrual syndrome and, with endometriosis, leads to the reverse development of endometrial formations.

Barrier methods of contraception:

condoms

Condoms as a method of contraception are most indicated for the category of women who do not have regular sexual intercourse with different partners. Since this remedy, in addition to the contraceptive effect, also has protective function from penetration various infections sexually transmitted.

In addition, the condom is easy to use. disadvantage this method is a slight decrease in sensitivity during intercourse in a man.

IUD (spiral)

The spiral prevents the penetration of sperm into the uterus, shortens the period of ovulation, and prevents the fertilized egg from attaching to the uterine cavity. In terms of reliability, this method is considered quite effective. The spiral is installed and removed by the doctor.

The term of use of the spiral is quite long, but like Mirena, it needs to be changed after 5 years. The disadvantages of this method include high probability ectopic pregnancy and more than usual exposure to sexually transmitted infections.

Chemical contraceptives

Spermicides

Spermicides are inserted into the vagina just before intercourse. Contraception achieves by influencing the spermatozoa, making them not viable. This method is ineffective, besides, it can cause irritation of the vaginal mucosa.

From the point of view of the aesthetic and emotional state during intercourse, he is also inferior to everyone else.

calendar method:

This method is the least reliable in terms of contraception. Its advantage is only that it is the only acceptable for people of deep faith. Since it is accepted by both the Orthodox and Catholic churches.

Coitus interruptus:

Oddly enough, despite its emotional and physical inconvenience, in Russia this method is used very often. Coitus interruptus does not guarantee against unwanted pregnancy, and unlike a condom, it does not protect against the transmission of infections.

Sterilization:

This method gives the greatest guarantee of contraception. But he, in turn, is not a reversible method of contraception. In rare cases, even after sterilization, conception is possible, but as a rule, pregnancy occurs ectopic. In addition, this method requires surgical intervention and the use of anesthesia.

Injectable contraceptives:

This is the introduction of injections or sewing in capsules. This method is one of the most inconvenient for a woman, because. causes negative emotions during its implementation. In addition, it is often accompanied by spotting bloody discharge in women.

Summing up, we can say that of all the methods of contraception, the most progressive are:

Oral contraceptives, patches, ring, Mirena and condoms. Each of them has its own advantages and disadvantages. Of course, none of the methods provides a 100% guarantee, but still any of the above methods is better than abortion.

In any case, before determining the most suitable method of contraception for yourself, you should seek the advice of a gynecologist.

And do not forget to visit him regularly and during the use of a contraceptive.

Gynecology: textbook / B. I. Baisova and others; ed. G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.

Chapter 20

Chapter 20

Drugs used to prevent pregnancy are called contraceptive. Contraception - component system of family planning and is aimed at regulating the birth rate, as well as maintaining the health of women. Firstly, the use of modern methods of contraception reduces the frequency of abortions as the main cause of gynecological pathology, miscarriage, maternal and perinatal mortality. Secondly, contraceptives serve to regulate the onset of pregnancy depending on the health of the spouses, compliance with the interval between births, the number of children, etc. Thirdly, some of the contraceptives have protective properties against malignant neoplasms, inflammatory diseases of the genital organs, postmenopausal osteoporosis, and serve as a powerful tool in the fight against a number of gynecological diseases - infertility, ovarian apoplexy, menstrual irregularities, etc.

An indicator of the effectiveness of any contraceptive is the Pearl Index - the number of pregnancies that occurred within 1 year in 100 women who used one or another method of contraception.

Modern methods of contraception are divided into:

Intrauterine;

Hormonal;

barrier;

natural;

Surgical (sterilization).

20.1. intrauterine contraception

Intrauterine contraception (IUD)- this is contraception with the help of funds introduced into the uterine cavity. The method is widely used in Asian countries (primarily in China), Scandinavian countries, and Russia.

The history of intrauterine contraception dates back to ancient times. However, the first such remedy was proposed in 1909 by the German gynecologist Richter: a ring from the gut of a silkworm, fastened with a metal wire. Then a gold or silver ring with an internal disk (Ott ring) was offered, but since 1935 the use of the IUD was prohibited.

in connection with high risk development of inflammatory diseases of the internal genital organs.

Interest in this method of contraception revived only in the 60s of the XX century. In 1962, Lipps used a flexible plastic in the form of a double Latin letter "S" to create a contraceptive, which made it possible to insert it without significant expansion of the cervical canal. A nylon thread was attached to the device to remove the contraceptive from the uterine cavity.

Types of intrauterine contraceptives. IUDs are divided into inert (non-drug) and drug-induced. The former include plastic IUDs of various shapes and designs, including the Lipps loop. Since 1989, WHO has recommended abandoning inert IUDs as ineffective and often causing complications. Medical IUDs have a plastic base of various configurations (loop, umbrella, number "7", letter "T", etc.) with the addition of a metal (copper, silver) or a hormone (levonorgestrel). These additives increase contraceptive effectiveness and reduce the number of adverse reactions. In Russia, the most commonly used:

Copper-containing Multiload- Si 375 (numbers indicate the surface area of ​​the metal, in mm 2), designed for 5 years of use. It has an F-shape with spike-like protrusions for retention in the uterine cavity;

-Nova-T- T-shaped with a copper winding area of ​​200 mm 2 for 5 years of use;

Cooper T 380 A - T-shaped with high content copper; term of use - 6-8 years;

Hormonal intrauterine system"Mirena" *, combining the properties of intrauterine and hormonal contraception, is a T-shaped contraceptive with a semi-permeable membrane through which levonorgestrel (20 μg / day) is released from a cylindrical reservoir. The term of use is 5 years.

Mechanism of action. The contraceptive effect of the IUD provides a decrease in the activity or death of spermatozoa in the uterine cavity (the addition of copper enhances the spermatotoxic effect) and an increase in the activity of macrophages that absorb spermatozoa that have entered the uterine cavity. When using an IUD with levonorgestrel, thickening of the cervical mucus under the influence of a progestogen creates an obstacle to the passage of spermatozoa into the uterine cavity.

In case of fertilization, the abortive effect of the IUD is manifested:

Increased peristalsis of the fallopian tubes, which leads to the penetration into the uterine cavity of the ovum, which is not yet ready for implantation;

The development of aseptic inflammation in the endometrium as a reaction to a foreign body, which causes enzyme disorders (the addition of copper enhances the effect) that prevents the implantation of a fertilized egg;

Increased contractile activity of the uterus itself as a result of an increase in the synthesis of prostaglandins;

Atrophy of the endometrium (for the intrauterine hormone-containing system) makes it impossible for the process of implantation of the fetal egg.

The hormone-containing IUD, having a local effect on the endometrium due to the constant release of progestogen, inhibits proliferation processes and causes atrophy of the uterine mucosa, which is manifested by a decrease in the duration of menstruation or amenorrhea. At the same time, levo-norgestrel does not have a noticeable systemic effect on the body while maintaining ovulation.

The contraceptive effectiveness of the IUD reaches 92-98%; the Pearl index ranges from 0.2-0.5 (when using a hormone-containing IUD) to 1-2 (when using an IUD with copper additives).

An intrauterine contraceptive can be inserted on any day of the menstrual cycle if you are sure that there is no pregnancy, but it is more expedient to do this on the 4-8th day from the onset of menstruation. IUD can be inserted immediately after abortion or 2-3 months after childbirth, and after caesarean section - not earlier than 5-6 months. Before the introduction of the IUD, the patient should be interviewed to identify possible contraindications, a gynecological examination and a bacterioscopic examination of smears from the vagina, cervical canal, and urethra for microflora and purity should be carried out. IUD can only be administered with smears of I-II purity. When using a contraceptive, you should carefully follow the rules of asepsis and antisepsis.

Within 7-10 days after the introduction of the IUD, it is recommended to limit physical activity, do not take hot baths, laxatives and uterotonics, and exclude sexual activity. The woman should be informed about the timing of the use of the IUD, as well as the symptoms possible complications requiring immediate medical attention. A second visit is recommended 7-10 days after the introduction of the IUD, then in a normal state - after 3 months. Medical examination of women using IUDs includes visiting a gynecologist twice a year with microscopy of smears from the vagina, cervical canal and urethra.

The IUD is removed at the request of the patient, as well as due to the expiration of the period of use (when replacing the used IUD with a new break, you can not do), with the development of complications. The IUD is removed by sipping on the "antennae". In the absence or breakage of the "antennae" (if the period of use of the IUD is exceeded), it is recommended to carry out the procedure in a hospital. It is advisable to clarify the presence and location of the contraceptive using ultrasound. The IUD is removed after dilation of the cervical canal under hysteroscopy control. The location of the IUD in the uterine wall, which does not cause complaints from the patient, does not require removal of the IUD, since this can lead to serious complications.

Complications. With the introduction of the IUD, perforation of the uterus is possible (1 in 5000 injections) up to the location of the contraceptive in the abdominal cavity. Perforation is manifested by acute pain in the lower abdomen. The complication is diagnosed using ultrasound of the pelvic organs, hysteroscopy. With partial perforation, you can remove the contraceptive by pulling on the "antennae". Complete perforation requires laparoscopy or laparotomy. Cha-

static perforation of the uterus often goes unnoticed and is detected only when unsuccessful attempt removal of the IUD.

Most frequent complications VMK are pain, bleeding like menometrorrhagia, inflammatory diseases of the internal genital organs. Constant intense pain most often indicates a discrepancy between the size of the contraceptive and the uterus. Cramping pains in the lower abdomen and bloody discharge from the genital tract - a sign of expulsion of the IUD (spontaneous expulsion from the uterine cavity). The frequency of expulsions (2-9%) can be reduced by prescribing one of the NSAIDs after the introduction of the IUD (indomethacin, diclofenac - voltaren *, etc.)

The combination of pain with fever, purulent or suicidal-purulent discharge from the vagina indicates the development of inflammatory complications (0.5-4%). The disease is especially severe, with severe destructive changes in the uterus and appendages, and often requires radical surgical interventions. To reduce the frequency of such complications, prophylactic antibiotics are recommended for 5 days after IUD insertion.

Uterine bleeding is the most common (1.5-24%) complication of intrauterine contraception. These are menorrhagia, less often - metrorrhagia. An increase in menstrual blood loss leads to the development of iron deficiency anemia. The appointment of NSAIDs in the first 7 days after the introduction of the IUD increases the acceptability of this method of contraception. A positive effect is given by the appointment of combined oral contraceptives (COCs) 2-3 months before the introduction of the IUD and in the first 2-3 months after it, which facilitate the adaptation period. If periods remain heavy, the IUD should be removed. With the appearance of metrorrhagia, hysteroscopy and separate diagnostic curettage are indicated.

Pregnancy with the use of IUDs is rare, but still not excluded. The frequency of spontaneous miscarriages with the use of IUDs increases. However, if desired, such a pregnancy can be saved. The question of the need and timing of removal of the IUD remains controversial. There is an opinion about the possibility of extracting the IUD on early dates but this can lead to miscarriage. Other experts consider it acceptable not to remove the contraceptive during pregnancy, believing that the IUD does not adversely affect the fetus due to its extra-amniotic location. Usually, the IUD is released along with the placenta and fetal membranes in the third stage of labor. Some authors suggest terminating a pregnancy that occurs with the use of an IUD, since its prolongation increases the risk of septic abortion.

IUD significantly reduces the possibility of pregnancy, including ectopic. However, the incidence of ectopic pregnancy in these cases is higher than in the general population.

Fertility after removal of the IUD in most cases is restored immediately. With the use of IUDs, there was no increase in the risk of developing cancer of the cervix and body of the uterus, ovaries.

Contraindications. Absolute contraindications include:

Pregnancy;

Acute or subacute inflammatory diseases of the pelvic organs;

Chronic inflammatory diseases of the pelvic organs with frequent exacerbations;

Malignant neoplasms of the cervix and body of the uterus. Relative contraindications:

Hyperpolymenorrhea or metrorrhagia;

Hyperplastic processes of the endometrium;

Algomenorrhea;

Hypoplasia and anomalies in the development of the uterus that prevent the introduction of the IUD;

Stenosis of the cervical canal, deformity of the cervix, isthmic-cervical insufficiency;

Anemia and other blood diseases;

Submucosal uterine myoma (small nodes without deformation of the cavity are not a contraindication);

Severe extragenital diseases of inflammatory etiology;

Frequent expulsions of the IUD in history;

Allergy to copper, hormones (for medical IUDs);

No history of childbirth. However, some experts allow the use of IUDs in nulliparous women with a history of abortion, subject to one sexual partner. In nulliparous patients, the risk of complications associated with the use of IUDs is higher.

It should be emphasized that many contraindications for the use of conventional IUDs become indications for the appointment of hormone-containing IUDs. Thus, levonorgestrel contained in Mirena ♠ has a therapeutic effect in hyperplastic processes of the endometrium after a histological diagnosis, in uterine myoma, in menstrual irregularities, reducing menstrual blood loss and eliminating pain.

The advantages of intrauterine contraception include:

High efficiency;

Possibility of long-term use;

Immediate contraceptive action;

Rapid restoration of fertility after removal of the IUD;

Lack of connection with sexual intercourse;

Low cost (with the exception of the hormonal intrauterine system);

Possibility of use during lactation;

Therapeutic effect in some gynecological diseases (for the hormonal intrauterine system).

The disadvantages are the need for medical manipulations during the introduction and removal of the IUD and the possibility of complications.

20.2. Hormonal contraception

One of the most effective and widespread methods of birth control has become hormonal contraception.

The idea of ​​hormonal contraception arose at the beginning of the 20th century, when the Austrian physician Haberland discovered that the administration of an ovarian extract causes temporary sterilization. After the discovery of sex hormones (estrogen - in 1929 and progesterone - in 1934), an attempt was made to synthesize artificial hormones, and in 1960 the American scientist Pincus et al. created the first contraceptive pill "Enovid". Hormonal contraception has developed along the path of reducing the dose of steroids (estrogens) and along the path of creating selective (selective action) gestagens.

At the 1st stage, preparations were created with a high content of estrogen (50 micrograms) and many serious side effects. At the 2nd stage, contraceptives with a low content of estrogens (30-35 mcg) and progestogens with a selective effect appeared, which made it possible to significantly reduce the number of complications when taking them. III generation drugs include agents containing low (30-35 mcg) or minimal (20 mcg) doses of estrogens, as well as highly selective progestogens (norgestimate, desogestrel, gestodene, dienogest, drospirenone), which have an even greater advantage over their predecessors.

Composition of hormonal contraceptives. All hormonal contraceptives (HC) consist of an estrogen and a progestogen or only a progestogen component.

Ethinyl estradiol is currently used as an estrogen. Along with the contraceptive effect, estrogens cause endometrial proliferation, prevent rejection of the uterine mucosa, providing a hemostatic effect. The lower the dose of estrogens in the preparation, the higher the possibility of the appearance of "intermenstrual" bleeding. Currently, HA is prescribed with an ethinylestradiol content of not more than 35 μg.

Synthetic gestagens (progestogens, synthetic progestins) are divided into progesterone derivatives and nortestosterone derivatives (norsteroids). Progesterone derivatives (medroxyprogesterone, megestrol, etc.) when taken orally do not give a contraceptive effect, since they are destroyed by gastric juice. They are mainly used for injectable contraception.

Norsteroids of the 1st generation (norethisterone, ethinodiol, linestrenol) and more active norsteroids of the 2nd (norgestrel, levonorgestrel) and III (norgestimate, gestodene, desogestrel, dienogest, drospirenone) generations after absorption into the blood bind to progesterone receptors, exerting a biological effect. The gestagenic activity of norsteroids is assessed by the degree of binding to progesterone receptors; it is much higher than that of progesterone. In addition to the gestagenic, norsteroids give expressed to varying degrees androgenic, anabolic and mineralocorticoid

effects due to interaction with the corresponding receptors. Third-generation gestagens, on the contrary, have an antiandrogenic effect on the body as a result of an increase in the synthesis of globulin that binds free testosterone in the blood, and high selectivity (the ability to bind to progesterone receptors to a greater extent than with androgen receptors), as well as an antimineralocorticoid effect (drospirenone ). GC classification:

Combined estrogen-progestin contraceptives:

Oral;

vaginal rings;

plasters;

Gestagen contraceptives:

Oral contraceptives containing microdoses of gestagens (mini-pills);

Injectable;

Implants.

Combined oral contraceptives (COCs) - these are tablets containing estrogen and progestogen components (Table 20.1).

Mechanism of action COC is diverse. The contraceptive effect is achieved as a result of the blockade of cyclic processes of the hypothalamic-pituitary system in response to the administration of steroids (feedback principle), and also due to the direct inhibitory effect on the ovaries. As a result, there is no growth, development of the follicle and ovulation. In addition, progestogens, by increasing the viscosity of cervical mucus, make it impassable for spermatozoa. Finally, the gestagenic component slows down the peristalsis of the fallopian tubes and the movement of the egg through them, and in the endometrium causes regressive changes up to atrophy, as a result of which the implantation of the fetal egg, if fertilization does occur, becomes impossible. This mechanism of action ensures high reliability of COCs. When used correctly, contraceptive efficacy reaches almost 100%, the Pearl index is

0,05-0,5.

According to the level of ethinyl estradiol, COCs are divided into high-dose (more than 35 mcg; currently not used for contraception), low-dose (30-35 mcg) and microdosed (20 mcg). In addition, COCs are monophasic, when all the tablets included in the package have the same composition, and multi-phase (two-phase, three-phase), when the package, designed for a cycle of administration, contains two or three types of tablets of different colors, differing in the amount of estrogen and progestogen components. Gradual dosage causes cyclic processes in the target organs (uterus, mammary glands), resembling those during a normal menstrual cycle.

Complications when taking COCs. In connection with the use of new low- and micro-dose COCs containing highly selective progestogens, side effects with the use of HA are rare.

Table 20.1. Currently used COCs, indicating the composition and dose of their components

In a small percentage of women taking COCs, in the first 3 months of use, discomfort associated with the metabolic action of sex steroids is possible. Estrogen-dependent effects include nausea, vomiting, swelling, dizziness, heavy menstrual-like bleeding, and gestagen-dependent effects include irritability, depression, fatigue, decreased libido. Headache, migraine, engorgement of the mammary glands, bleeding may be due to the action of both components of the COC. At present, these signs are

are seen as symptoms of adaptation to COCs; usually they do not require the appointment of corrective agents and disappear on their own by the end of the 3rd month of regular use.

The most serious complication when taking COCs is the effect on the hemostasis system. It has been proven that the estrogen component of COCs activates the blood coagulation system, which increases the risk of thrombosis, primarily coronary and cerebral, as well as thromboembolism. The possibility of thrombotic complications depends on the dose of ethinyl estradiol included in COCs and risk factors, which include age over 35 years, smoking, hypertension, hyperlipidemia, obesity, etc. It is generally accepted that the use of low or microdose COCs does not significantly affect the hemostasis system in healthy people. women.

When taking COCs, blood pressure rises, which is due to the influence of the estrogen component on the renin-angiotensin-aldosterone system. However, this phenomenon was noted only in women with an unfavorable anamnesis (hereditary predisposition, obesity, hypertension in the present, OPG-preeclampsia in the past). Clinically significant changes in blood pressure in healthy women taking COCs have not been identified.

When using COCs, a number of metabolic disorders are possible:

Decreased tolerance to glucose and an increase in its level in the blood (estrogenic effect), which provokes the manifestation latent forms diabetes;

The adverse effect of gestagens on lipid metabolism (increased levels of total cholesterol and its atherogenic fractions), which increases the risk of atherosclerosis and vascular complications. However, modern selective gestagens, which are part of third-generation COCs, do not adversely affect lipid metabolism. In addition, the effect of estrogens on lipid metabolism is directly opposite to the effect of gestagens, which is regarded as a factor in the protection of the vascular wall;

Weight gain due to the anabolic effect of gestagens, fluid retention due to the influence of estrogen, increased appetite. Modern COCs with a low content of estrogens and selective progestogens have practically no effect on body weight.

Estrogens may have little toxic effect on the liver, manifested in a transient increase in the level of transaminases, cause intrahepatic cholestasis with the development of cholestatic hepatitis and jaundice. Gestagens, by increasing the concentration of cholesterol in bile, contribute to the formation of stones in bile ducts and bubble.

Acne, seborrhea, hirsutism are possible with the use of gestagens with a pronounced androgenic effect. The currently used highly selective progestogens, on the contrary, have an antiandrogenic effect, and they provide not only a contraceptive, but also a therapeutic effect.

A sharp deterioration in vision when using COCs is a consequence of acute retinal thrombosis; in this case, immediate withdrawal of the drug is required. It should be borne in mind that COCs when using contact lenses cause swelling of the cornea with the appearance of a feeling of discomfort.

A rare but worrying complication is amenorrhea following discontinuation of COCs. There is an opinion that COCs do not cause amenorrhea, but only hide hormonal disorders due to regular menstrual-like blood secretions. Such patients should definitely be examined for a pituitary tumor.

Long-term use of COCs changes the microecology of the vagina, contributing to the occurrence of bacterial vaginosis, vaginal candidiasis. In addition, the use of COCs is considered as a risk factor for the transition of existing cervical dysplasia to carcinoma. Women taking COCs should have regular cytological studies smears from the cervix.

Any of the components of COCs can cause an allergic reaction.

One of the most common side effects is uterine bleeding when using COCs (from "spotting" to "breakthrough"). The causes of bleeding are the lack of hormones for a particular patient (estrogens - with the appearance of blood discharge in the 1st half of the cycle, gestagens - in the 2nd half), malabsorption of the drug (vomiting, diarrhea), missed pills, competitive action taken together with COCs drugs (some antibiotics, anticonvulsants, β-blockers, etc.). In most cases, intermenstrual bleeding disappears on its own during the first 3 months of taking COCs and does not require the abolition of contraceptives.

COCs do not have a negative effect on fertility in the future (it is restored in most cases within the first 3 months after discontinuation of the drug), do not increase the risk of fetal defects. Accidental use of modern hormonal contraceptives in early pregnancy does not give a mutagenic, teratogenic effect and does not require termination of pregnancy.

To the contraceptive benefits of COCs include:

High efficiency and almost immediate contraceptive effect;

Reversibility of the method;

Low frequency of side effects;

Good fertility control;

Lack of connection with sexual intercourse and influence on the sexual partner;

Eliminate the fear of unwanted pregnancy;

Ease of use. Non-contraceptive benefits of COCs:

Reducing the risk of developing ovarian cancer (by 45-50%), endometrial cancer (by 50-60%), benign breast diseases (by 50-75%), uterine fibroids (by 17-31%), postmenopausal osteoporosis (increased mineralization bone tissue), colorectal cancer (by 17%);

Reducing the incidence of inflammatory diseases of the pelvic organs (by 50-70%) as a result of an increase in the viscosity of cervical mucus, ectopic pregnancy, retention

vanes (cysts) of the ovary (up to 90%), iron deficiency anemia due to less blood loss during menstrual-like discharge than during normal menstruation;

Relief of symptoms of premenstrual syndrome and dysmenorrhea;

Therapeutic effect in acne, seborrhea, hirsutism (for third-generation COCs), endometriosis, uncomplicated cervical ectopia (for three-phase COCs), in some forms of infertility accompanied by ovulation disorders (rebound effect after withdrawal

COOK);

Increasing the acceptability of IUDs;

Positive effect on flow rheumatoid arthritis. The protective effect of COCs appears already after 1 year of use, increases with increasing duration of use and persists for 10-15 years after withdrawal.

Disadvantages of the method: the need for daily intake, the possibility of errors in admission, the lack of protection against sexually transmitted infections, a decrease in the effectiveness of COCs while taking other drugs.

Indications. Currently, according to WHO criteria, hormonal contraception is recommended for women of any age who wish to limit their reproductive function:

In the post-abortion period;

In the postpartum period (3 weeks after childbirth, if the woman is not breastfeeding);

With a history of ectopic pregnancy;

Those who have undergone inflammatory diseases of the pelvic organs;

With menometrorrhagia;

With iron deficiency anemia;

With endometriosis, fibrocystic mastopathy (for monophasic

COOK);

FROM premenstrual syndrome, dysmenorrhea, ovulatory syndrome;

With retention formations of the ovaries (for monophasic COCs);

With acne, seborrhea, hirsutism (for COCs with III generation progestogens). Contraindications. Absolute contraindications to the appointment of COC:

Hormonally dependent malignant tumors(tumors of the genital organs, breast) and tumors of the liver;

Severe violations of the liver and kidneys;

Pregnancy;

Severe cardiovascular disease, cerebrovascular disease;

Bleeding from the genital tract of unknown etiology;

Severe hypertension (BP above 180/110 mm Hg);

Migraines with focal neurological symptoms;

Acute deep vein thrombosis, thromboembolism;

Prolonged immobilization;

A period including 4 weeks before abdominal surgery and 2 weeks after them (increased risk of thrombotic complications);

Smoking and age over 35;

Diabetes mellitus with vascular complications;

Obesity III-IV degree;

Lactation (estrogens pass into breast milk).

The possibility of using oral contraception for other diseases, the course of which COCs can affect, is determined individually.

Conditions requiring immediate cancellation of the GC:

sudden severe headache;

Sudden impairment of vision, coordination, speech, loss of sensation in the limbs;

Acute chest pain, unexplained shortness of breath, hemoptysis;

Acute pain in the abdomen, especially prolonged;

sudden pain in the legs;

Significant increase in blood pressure;

Itching, jaundice;

Skin rash.

Rules for taking COCs. COCs begin to be taken from the 1st day of the menstrual cycle: 1 tablet daily at the same time of day for 21 days (as a rule, the drug package contains 21 tablets). It should be remembered that multiphase drugs must be taken in a strictly specified sequence. Then they take a 7-day break, during which a menstrual-like reaction occurs, after which a new cycle of administration begins. When performing an artificial abortion, you can start taking COCs on the day of the operation. If a woman is not breastfeeding, the need for contraception occurs 3 weeks after birth. If it is necessary to delay menstrual bleeding, a break in taking the drugs can be avoided by continuing to take the pills. next package(for multi-phase contraceptives, only tablets of the last phase are used for this).

For microdosed COC jess* containing 28 tablets per pack, the regimen is as follows: 24 active tablets followed by 4 placebo tablets. Thus, the action of hormones is extended for another 3 days, and the presence of placebo tablets facilitates adherence to the contraceptive regimen.

There is another scheme for the use of monophasic COCs: taking 3 cycles of tablets in a row, then a 7-day break.

If the interval between taking the tablets was more than 36 hours, the reliability of the contraceptive action is not guaranteed. If a tablet is missed on the 1st or 2nd week of the cycle, then the next day you need to drink 2 tablets, and then take the tablets as usual, using additional contraception for 7 days. If the gap was 2 tablets in a row for the 1st or 2nd week, then in the next 2 days you should take 2 tablets, then continue taking the tablets as usual, using additional methods of contraception until the end of the cycle. If you miss a pill in the last week of the cycle, it is recommended to start taking the next pack without interruption.

When used correctly, COCs are safe. The duration of administration does not increase the risk of complications, so COCs can be used for as many years as necessary, up to the onset of postmenopause. It has been proven that taking breaks in taking drugs is not only unnecessary, but also risky, since during this period the likelihood of an unwanted pregnancy increases.

Vaginal ring "NovaRing" ♠ refers to estrogen-progestin contraception with parenteral delivery of hormones to the body. The No-Varing* is a flexible plastic ring that is inserted deep into the vagina from day 1 to day 5 of the menstrual cycle for 3 weeks and then removed. After a 7-day break, during which bleeding occurs, a new ring is introduced. Being in the vagina, "NovaRing" * daily releases a constant small dose of hormones (15 μg of ethinyl estradiol and 120 μg of the progestogen etonogestrel), which enter the systemic circulation, which provides reliable contraception (Pearl index - 0.4). "NovaRing" * does not interfere with an active lifestyle, playing sports, swimming. There were no cases of prolapse of the ring from the vagina. Any discomfort partners during sexual contact the vaginal ring does not cause.

Using transdermal contraceptive system "Evra" * the combination of estrogen and progestogen enters the body from the surface of the patch through the skin, blocking ovulation. 20 micrograms of ethnylestradiol and 150 micrograms of norelgestramine are absorbed daily. One package contains 3 patches, each of which is alternately glued for 7 days on the 1st, 8th, 15th days of the menstrual cycle. The patches are attached to the skin of the buttocks, abdomen, shoulders. On the 22nd day, the last patch is removed, and the next pack is started after a week break. The patch is securely attached to the skin, does not interfere with active image life, does not peel off either during water procedures or under the influence of the sun.

Transvaginal and transdermal routes of entry of contraceptive hormones into the body have a number of advantages over oral ones. First, a smoother flow of hormones throughout the day provides good cycle control. Secondly, due to the lack of primary passage of hormones through the liver, a smaller daily dose is required, which reduces the negative side effects of hormonal contraception to a minimum. Thirdly, there is no need to take a daily pill, which eliminates the violation of the correct use of a contraceptive.

Indications, contraindications, negative and positive effects NovaRinga ♠ and Evra patches ♠ are the same as for COC.

Oral progestin contraceptives (OGCs) contain small doses of progestogens (mini-pills) and were created as an alternative to COCs. OGK is used in women who are contraindicated in drugs containing estrogens. The use of pure gestagens, on the one hand, reduces the number of complications of hormonal contraception, and on the other hand, reduces the acceptability of this type of contraception. Due to the lack of estrogens to prevent endometrial rejection, intermenstrual bleeding is often observed when taking OGK.

OGKs include Demulene* (ethinodiol 0.5 mg), Microlut* (levonorgestrel 0.03 mg), Exluton* (linestrenol 0.5 mg), Charosetta* (desogestrel

0.075 mg).

ActionWGC due to an increase in the viscosity of cervical mucus, the creation of unfavorable conditions for the implantation of a fertilized egg in the endometrium, and a decrease in the contractility of the fallopian tubes. The dose of steroids in the minipill is insufficient to effectively suppress ovulation. More than half of women taking OGKs have normal ovulatory cycles, so the contraceptive effectiveness of OGKs is lower than COCs; the Pearl index is 0.6-4.

Currently, only a few women use this method of contraception. Basically, they are breastfeeding (OGCs are not contraindicated in lactation), smokers, women in the late reproductive period, with contraindications to the estrogen component of COCs.

Mini-pills are taken from the 1st day of menstruation, 1 tablet per day in continuous mode. It should be remembered that the effectiveness of OGK decreases when a dose is missed, which is 3-4 hours. Such a violation of the regimen requires the use of additional methods of contraception for at least 2 days.

To the above contraindications due to gestagens, it is necessary to add a history of ectopic pregnancy (gestagens slow down the transport of the egg through the tubes) and ovarian cysts (gestagens often contribute to the occurrence of ovarian retention formations).

Advantages of OGK:

Less systemic effect on the body compared to COCs;

No estrogen-dependent side effects;

Possibility of use during lactation. Disadvantages of the method:

Less contraceptive efficacy compared to COCs;

High chance of bleeding.

Injectable contraceptives used for prolonged contraception. Currently, Depo-Provera * containing medroxyprogesterone is used for this purpose. The Pearl Index of injectable contraception does not exceed 1.2. the first intramuscular injection do in any of the first 5 days of the menstrual cycle, the next - every 3 months. The drug can be administered immediately after an abortion, after childbirth if the woman is not breastfeeding, and 6 weeks after childbirth when breastfeeding.

Mechanism of action and contraindications to the use of depo-prover * are similar to those for OGK. Advantages of the method:

High contraceptive efficiency;

No need for daily intake of the drug;

Duration of action;

Few side effects;

Absence of estrogen-dependent complications;

The ability to use the drug with therapeutic purpose with hyperplastic processes of the endometrium, benign diseases of the mammary glands, uterine myoma, adenomyosis.

Disadvantages of the method:

Delayed restoration of fertility (from 6 months to 2 years after the termination of the drug);

Frequent bleeding (subsequent injections lead to amenorrhea).

Injectable contraception is recommended for women who need long-term reversible contraception, during lactation, who have contraindications to the use of estrogen-containing drugs, and who do not want to take hormonal contraceptives daily.

Implants provide a contraceptive effect as a result of constant long-term release of a small amount of gestagens. In Russia, Norplant * is registered as an implant, containing levonorgestrel and representing 6 silastic capsules for subcutaneous injection. The level of levonorgestrel required for contraception is reached within 24 hours after administration and persists for 5 years. Capsules are injected under the skin of the inner side of the forearm fan-shaped through a small incision under local anesthesia. The Pearl Index for norplant is 0.2-1.6. The contraceptive effect is provided as a result of the suppression of ovulation, an increase in the viscosity of cervical mucus and the development of atrophic changes in the endometrium.

Norplant is recommended for women who need long-term (at least 1 year) reversible contraception, with estrogen intolerance, who do not want to take hormonal contraceptives daily. After the expiration date or at the request of the patient, the contraceptive is removed surgically. Fertility is restored within a few weeks after the capsules are removed.

In addition to Norplant, there is a single-capsule implantable contraceptive Implanon p * containing etonogestrel, a highly selective progestogen of the latest generation, a biologically active metabolite of desogestrel. Implanon is inserted and removed four times faster than a multi-capsule preparation; complications are less common (less than 1%). Implanon provides long-term contraception for 3 years, high efficiency, lower incidence of adverse reactions, rapid restoration of fertility and therapeutic effects inherent in progestin contraceptives.

Advantages of the method: high efficiency, duration of contraception, safety (a small number of side effects), reversibility, absence of estrogen-dependent complications, no need to take the drug daily.

Disadvantages of the method: frequent occurrence of bleeding, the need for surgical intervention for the introduction and removal of capsules.

* This drug is currently being registered with the Ministry of Health and social development RF in the Department of State Regulation of Medicines Circulation.

20.3. barrier methods of contraception

Currently, due to the increase in the number of sexually transmitted diseases, the number of people using barrier methods has increased. Barrier methods of contraception are divided into chemical and mechanical.

Chemical methods of contraception (spermicides) - this is chemical substances detrimental to spermatozoa. The main spermicides that are part of ready-made forms, are nonoxynol-9 and benzalkonium chloride. They destroy the cell membrane of spermatozoa. The effectiveness of the contraceptive action of spermicides is low: the Pearl index is 6-20.

Spermicides are available in the form of vaginal tablets, suppositories, pastes, gels, creams, films, foams with special nozzles for intravaginal administration. Benzalkonium chloride (pharmatex *) and nonoxynol (patentex oval *) deserve special attention. Candles, tablets, films with spermicides are injected into the upper part of the vagina 10-20 minutes before sexual intercourse (the time required for dissolution). Cream, foam, gel immediately after administration exhibit contraceptive properties. With repeated sexual intercourse, additional administration of spermicides is required.

There are special polyurethane sponges impregnated with spermicides. Sponges are inserted into the vagina before sexual intercourse (it is possible a day before sexual intercourse). They have the properties of chemical and mechanical contraceptives, since they create a mechanical barrier to the passage of spermatozoa and secrete spermicides. It is recommended to leave the sponge for at least 6 hours after intercourse for the reliability of the contraceptive effect, but it must be removed no later than 30 hours. If a sponge is used, then repeated sexual intercourse does not require additional administration of spermicide.

In addition to the contraceptive effect, spermicides provide some protection against sexually transmitted infections, since the chemicals have a bactericidal, virocidal property. However, the risk of infection still remains, and for HIV infection it even increases due to the increase in the permeability of the vaginal wall under the influence of spermicides.

Advantages of chemical methods: short duration of action, no systemic effect on the body, few side effects, protection against sexually transmitted infections.

Disadvantages of methods: development opportunity allergic reactions, low contraceptive efficacy, connection of use with sexual intercourse.

To mechanical methods of contraception include condoms, cervical caps, vaginal diaphragms, which create a mechanical obstacle to the penetration of spermatozoa into the uterus.

The most widely used condoms. There are male and female condoms. The male condom is a thin, cylindrical latex or vinyl pouch; some condoms are treated with spermicides. A condom is put on

erect penis before intercourse. The penis should be removed from the vagina before the erection ceases to prevent the condom from slipping off and semen from entering the woman's genital tract. Cylindrical female condoms are made of polyurethane film and have two rings. One of them is inserted into the vagina and put on the neck, the other is taken out of the vagina. Condoms are single use.

Pearl index for mechanical methods ranges from 4 to 20. The effectiveness of a condom decreases when it is used incorrectly (use of fatty lubricants that destroy the surface of the condom, repeated use of the condom, intense and prolonged sexual intercourse, leading to microdefects of the condom, improper storage, etc.). Condoms are good protection against sexually transmitted infections, but infection viral diseases, syphilis is still not excluded when the damaged skin sick and healthy partner. Side effects include an allergy to latex.

This type of contraception is indicated for patients who have casual sex, with a high risk of infection, who rarely and irregularly live sexually.

For reliable protection against pregnancy and sexually transmitted infections, use the "double Dutch method" - a combination of hormonal (surgical or intrauterine) contraception and a condom.

The vaginal diaphragm is a dome-shaped device made of latex with an elastic rim around the edge. The diaphragm is inserted into the vagina before sexual intercourse so that the dome covers the cervix, and the rim is closely adjacent to the walls of the vagina. The diaphragm is usually used with spermicides. With repeated sexual intercourse after 3 hours, repeated administration of spermicides is required. After intercourse, leave the diaphragm in the vagina for at least 6 hours, but no more than 24 hours. The removed diaphragm is washed with soap and water and dried. The use of the diaphragm requires special training. It is not recommended to use the diaphragm for prolapsed vaginal walls, old perineal ruptures, large vaginal sizes, diseases of the cervix, inflammatory processes of the genital organs.

Cervical caps are metal or latex cups that are placed over the cervix. Caps are also used together with spermicides, injected before sexual intercourse, removed after 6-8 hours (maximum - after 24 hours). The cap is washed after use and stored in a dry place. Contraindications to contraception in this way are diseases and deformation of the cervix, inflammatory diseases of the genital organs, prolapse of the walls of the vagina, and the postpartum period.

Unfortunately, neither diaphragms nor caps protect against sexually transmitted infections.

To benefits mechanical means of contraception include the absence of a systemic effect on the body, protection against sexually transmitted infections (for condoms), shortcomings- the connection between the use of the method and sexual intercourse, insufficient contraceptive effectiveness.

20.4. Natural methods of contraception

The use of these methods of contraception is based on the possibility of pregnancy on days close to ovulation. To prevent pregnancy, abstain from sexual activity or use other methods of contraception on the days of the menstrual cycle with the highest probability of conception. Natural methods of contraception are ineffective: the Pearl index ranges from 6 to 40. This significantly limits their use.

To calculate the fertile period, use:

Calendar (rhythmic) method of Ogino-Knaus;

Measurement rectal temperature;

The study of cervical mucus;

symptothermal method.

Application calendar method based on the determination of the average timing of ovulation (average day 14 ± 2 days for a 28-day cycle), spermatozoa (average 4 days) and egg (average 24 hours). With a 28-day cycle, the fertile period lasts from the 8th to the 17th day. If the duration of the menstrual cycle is not constant (the duration of at least the last 6 cycles is determined), then the fertile period is determined by subtracting from the short cycle 18 days, of the longest - 11. The method is acceptable only for women with a regular menstrual cycle. With significant fluctuations in duration, almost the entire cycle becomes fertile.

temperature method based on the determination of ovulation by rectal temperature. The egg survives for a maximum of three days after ovulation. Fertile is the period from the onset of menstruation to the expiration of three days from the moment the rectal temperature rises. The long duration of the fertile period makes the method unacceptable for couples who have an active sex life.

cervical mucus during the menstrual cycle, it changes its properties: in the preovulatory phase, its amount increases, it becomes more extensible. A woman is trained to evaluate the cervical mucus over several cycles to determine the time of ovulation. Conception is likely within two days before the discharge of mucus and 4 days after. This method cannot be used for inflammatory processes in the vagina.

Symptothermal method based on the control of rectal temperature, properties of cervical mucus and ovulatory pain. The combination of all methods allows you to more accurately calculate the fertile period. The symptomatic method requires the patient to be thorough and persistent.

interrupted intercourse - one of the options for a natural method of contraception. Its advantages can be considered simplicity and lack of ma-

terial costs. However, the contraceptive effectiveness of the method is low (Pearl index - 8-25). Failures are explained by the possibility of getting pre-ejaculatory fluid containing spermatozoa into the vagina. For many couples, this type of contraception is unacceptable because self-control reduces satisfaction.

Natural methods of contraception are used by couples who do not want to use other methods of contraception for fear of side effects, as well as for religious reasons.

20.5. Surgical methods contraception

Surgical methods of contraception (sterilization) are used in both men and women (Fig. 20.1). Sterilization in women provides obstruction of the fallopian tubes, as a result of which fertilization is impossible. During sterilization in men, the vas deferens are tied up and crossed (vasectomy), after which spermatozoa cannot enter the ejaculate. Sterilization is the most effective method of contraception (Pearl index is 0-0.2). The onset of pregnancy, although extremely rare, is due to technical defects in the sterilization operation or recanalization of the fallopian tubes. It should be emphasized that sterilization refers to irreversible methods. The existing options for restoring the patency of the fallopian tubes (microsurgical operations) are complex and ineffective, and IVF is an expensive procedure.

Before the operation, a consultation is carried out, during which they explain the essence of the method, report its irreversibility, find out the details of the anam-

Rice. 20.1. Sterilization. Coagulation and division of the fallopian tube

neza, interfering with the implementation of sterilization, as well as conduct a comprehensive examination. All patients must receive a written informed consent to carry out the operation.

In our country, voluntary surgical sterilization has been allowed since 1993. According to the Basic Legislation of the Russian Federation on the protection of the health of citizens (Article 37), medical sterilization as a special intervention to deprive a person of the ability to reproduce offspring or as a method of contraception can be carried out only upon a written application of a citizen at least 35 years of age or having at least 2 children, and if available medical indications and with the consent of the citizen - regardless of age and the presence of children.

For medical indications include diseases or conditions in which pregnancy and childbirth are associated with health risks. Is the list of medical indications for sterilization determined by order? 121n dated 03/18/2009 of the Ministry of Health and Social Development of Russia.

Contraindications to sterilization are diseases in which the operation is impossible. As a rule, these are temporary situations, they only cause the postponement of the surgical intervention.

The optimal timing of the operation is the first few days after menstruation, when the likelihood of pregnancy is minimal, the first 48 hours after childbirth. Sterilization during caesarean section is possible, but only with written informed consent.

The operation is performed under general, regional or local anesthesia. Laparotomy, mini-laparotomy, laparoscopy are used. Laparotomy is used when sterilization is performed during another operation. The two most commonly used are the other two. With a mini-laparotomy, the length of the skin incision does not exceed 3-4 cm, it is performed in the postpartum period, when the uterine fundus is high, or in the absence of appropriate specialists and laparoscopic equipment. Each access has its own advantages and disadvantages. The time required to perform the operation, regardless of access (laparoscopy or mini-laparotomy) is 10-20 minutes.

The technique for creating occlusion of the fallopian tubes is different - ligation, cutting with ligatures (Pomeroy's method), removal of a segment of the tube (Parkland's method), coagulation of the tube (see Fig. 20.1), application of titanium clamps (Filshi's method) or silicone rings that compress the lumen of the tube .

The operation is associated with the risk of anesthetic complications, bleeding, hematoma formation, wound infections, inflammatory complications from the pelvic organs (with laparotomy), injuries of the abdominal organs and main vessels, gas embolism or subcutaneous emphysema (with laparoscopy).

In addition to the abdominal method of sterilization, there is a transcervical method, when during hysteroscopy, occlusive substances are injected into the mouths of the fallopian tubes. The method is currently considered experimental.

Vasectomy for men is a simpler and less dangerous procedure, but few in Russia resort to it because of the false fear of adverse effects on sexual function. Inability to conceive occurs in men 12 weeks after surgical sterilization.

Sterilization benefits: a one-time intervention that provides long-term protection against pregnancy, no side effects.

Disadvantages of the method: the need for a surgical operation, the possibility of complications, the irreversibility of the intervention.

20.6. Postcoital contraception

postcoital, or emergency, contraception called a method of preventing pregnancy after unprotected intercourse. The purpose of this method is to prevent pregnancy at the stage of ovulation, fertilization, implantation. The mechanism of action of postcoital contraception is diverse and manifests itself in the desynchronization of the menstrual cycle, disruption of the processes of ovulation, fertilization, transport and implantation of the fetal egg.

Emergency contraception should not be used regularly and should only be used in exceptional cases (rape, condom rupture, diaphragmatic displacement if other methods of contraception are not possible) or in women who have infrequent sexual intercourse.

The most common methods of postcoital contraception should be considered the introduction of an IUD or the use of sex steroids after intercourse.

For the purpose of emergency protection against pregnancy, the IUD is administered no later than 5 days after unprotected intercourse. At the same time, possible contraindications for the use of IUDs should be taken into account. This method can be recommended to patients who wish to continue to use permanent intrauterine contraception, in the absence of a risk of infection of the genital tract (contraindicated after rape).

For hormonal postcoital contraception, COCs (Yuzpe method), pure gestagens or antiprogestins are prescribed. The first COC intake according to the Yuzpe method is necessary no later than 72 hours after unprotected intercourse, the 2nd - 12 hours after the 1st dose. The total dose of ethinyl-stradiol should not be less than 100 micrograms per dose. Postinor ♠ containing 0.75 mg of levonorgestrel and escapel ♠ containing 1.5 mg of levonorgestrel have been created especially for postcoital progestational contraception. Postinor ♠ should be taken 1 tablet 2 times according to a scheme similar to the Yuzpe method. When using escapelle * 1 tablet must be used no later than 96 hours after unprotected intercourse. The antiprogestin mifepristone at a dose of 10 mg binds progesterone receptors and prevents or interrupts the process of preparation of the endometrium for implantation, due to the action of progesterone. A single dose of 1 tablet is recommended within 72 hours after sexual intercourse.

Before prescribing hormones, contraindications must be excluded.

The effectiveness of various methods of this type of contraception is on the Pearl index from 2 to 3 (medium reliability). High doses of hormones can cause side effects - uterine bleeding, nausea, vomiting, etc. A pregnancy should be considered a failure, which, according to WHO experts, must be interrupted due to the danger of the teratogenic effect of high doses of sex steroids. After using emergency contraception, it is advisable to conduct a pregnancy test, if the result is negative, choose one of the methods of planned contraception.

20.7. Teenage contraception

The WHO defines adolescents as young people between the ages of 10 and 19. Early onset of sexual activity puts teenage contraception in one of the first places, since the first abortion or childbirth at a young age can seriously affect health, including reproductive health. Sexual activity in adolescents increases the risk of sexually transmitted diseases.

Contraception in young people should be highly effective, safe, reversible and affordable. For adolescents, several types of contraception are considered acceptable.

Combined oral contraception - microdosed, low-dosed COCs with the latest generation of progestogens, three-phase COCs. However, the estrogens that are part of COCs can cause premature closure of the growth centers of the epiphyses of the bones. At present, it is considered acceptable to prescribe COCs with a minimum content of ethnylestradiol after the first 2-3 menstruations have passed in a teenage girl.

Postcoital contraception COCs or gestagens are used for unplanned sexual intercourse.

Condoms combined with spermicides provide protection against sexually transmitted infections.

The use of pure gestagens is unacceptable due to the frequent occurrence of blood discharge, and the use of IUDs is relatively contraindicated. Natural methods of contraception, spermicides are not recommended for adolescents due to their low efficiency, and sterilization is unacceptable as an irreversible method.

20.8. Postpartum contraception

Most women in the postpartum period are sexually active, so contraception after childbirth remains relevant. Currently, several types of postpartum contraception are recommended.

The lactational amenorrhea method (LAM) is a natural method of contraception based on the inability to conceive when

regular breastfeeding. Prolactin released during lactation blocks ovulation. The contraceptive effect is provided within 6 months after childbirth if the child is breastfed at least 6 times a day, and the intervals between feedings are no more than 6 hours (the "three sixes" rule). During this period, menstruation is absent. The use of other natural methods of contraception is ruled out because it is impossible to predict the time of the resumption of menstruation after childbirth, and the first menstruation is often irregular.

Postpartum sterilization is currently performed even before discharge from the maternity hospital. Gestagen oral contraception is allowed to be used during lactation. Prolonged progestogen contraception (depo-provera *, norplant *) can be started from the 6th week after childbirth while breastfeeding.

Condoms are used in combination with spermicides.

In the absence of lactation, it is possible to use any method of contraception (COC - from the 21st day, IUD - from the 5th week of the postpartum period).

The creation of contraceptive vaccines based on the achievements of genetic engineering is promising. As antigens, CG, antigens of sperm, egg, fetal egg are used.

A search is underway for contraceptives that cause temporary sterilization in men. Gossypol isolated from cotton, when taken orally, caused the cessation of spermatogenesis in men for several months. However, many side effects prevented the introduction of this method into practice. Research into the creation of hormonal contraception for men is ongoing. It has been proven that the production of male germ cells can be stopped by the administration of androgen and progestogen in the form of an injection or implant. After the termination of the drug, fertility is restored after 3-4 months.