Family Planning

Also written as Contraception, Birth Control, Planned Parenthood.

Family planning encompasses the practices and methods used by individuals to control their fertility and decide the timing and spacing of pregnancies. It is a cornerstone of reproductive health, reducing maternal and infant morbidity through managed contraception and preconception care.

Mechanism of Action

Contraceptive methods function by interrupting the physiological process of conception at different stages.

• Hormonal methods: Suppress ovulation via negative feedback on the HPO axis and thicken cervical mucus.
• Barrier methods: Physically prevent sperm from reaching the oocyte.
• Intrauterine devices (IUDs): Induce a sterile inflammatory response or release progestogen to prevent fertilization and implantation.
• Permanent methods: Surgical occlusion of the fallopian tubes or vas deferens.

Clinical Assessment

The choice of method is guided by medical eligibility criteria to ensure safety and efficacy.

• WHO Eligibility Criteria: Determines if a patient has contraindications, such as hypertension or history of VTE.
• Menstrual History: Assesses for underlying pathology and helps determine the timing for method initiation.

Physiological Regulation

Most hormonal contraceptives utilize synthetic estrogen and progestogen to inhibit the mid-cycle LH surge.

• Progestogen: Primary agent for suppressing ovulation and altering the endometrium.
• Estrogen: Added to improve cycle control and stabilize the endometrium.

Clinical Considerations and Failure

Method failure can occur due to biological factors or incorrect usage, leading to unintended pregnancy.

• User-dependent failure: Missing pills or incorrect barrier application.
• Metabolic interference: Certain medications (e.g., enzyme-inducing anticonvulsants) reduce hormonal efficacy.
• Expulsion: Spontaneous displacement of intrauterine devices.

Often confused with

• Pregnancy symptoms vs hormonal side effects: Nausea and breast tenderness occur in both; confirm status with a beta-hCG test.
• DMPA-induced amenorrhea vs premature ovarian insufficiency: Check clinical history and FSH levels if amenorrhea persists after stopping the injection.
• IUD expulsion vs lost strings: A malpositioned IUD causes pain/bleeding, while lost strings may simply be retracted into the cervical canal.

Where results can mislead

• Urine pregnancy tests: May remain positive for several weeks following a miscarriage or termination despite successful contraception initiation.
• Liver function tests: Combined hormonal contraceptives can cause transient elevations in transaminases without signifying chronic liver disease.
• Thyroid function tests: Estrogen increases thyroid-binding globulin, leading to elevated total T4 while free T4 remains normal.

Questions an examiner may ask

• List the UK Medical Eligibility Criteria (UKMEC) categories and provide examples for MEC 4 contraindications to combined oral contraceptives.
• Compare and contrast the side effect profiles of the levonorgestrel-releasing intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD).
• Describe the management and counseling required for a patient who has missed two consecutive doses of a combined oral contraceptive pill.

When to seek help

• Sudden, severe chest pain or shortness of breath while using combined hormonal contraceptives.
• Severe abdominal pain which may indicate ectopic pregnancy or IUD displacement.
• Unilateral leg swelling and tenderness suggestive of deep vein thrombosis.
• New onset of severe migraines or focal neurological deficits.

Quick questions

What is the mechanism of action of the Progestogen-Only Pill (POP)?

It primarily works by thickening cervical mucus to prevent sperm penetration and thinning the endometrium, though it may also inhibit ovulation in some cycles.

How long is the Copper IUD effective for?

The Copper IUD is highly effective for long-term contraception, typically lasting between 5 to 10 years depending on the specific model used.

Can breastfeeding be used as a reliable contraceptive method?

Yes, via the Lactational Amenorrhea Method (LAM), provided the infant is under six months, the mother is amenorrheic, and breastfeeding is exclusive.