Contraception

1. Contraception Shelley Mitchell

2. Issues • Decision made by individual or by couple • Many factors influence decision: • Advantages & disadvantages of various methods • Side effects & contraindications • Effectiveness • Perfect use vs. typical use • Expense • Spiritual/cultural beliefs • Practicality of method

3. Some facts • Correct & consistent use of contraceptives results in lower risk of pregnancy • Using more than one method together dramatically lowers risk of pregnancy • Emergency contraception offers last chance to prevent pregnancy after unprotected intercourse or when extent of protection isn’t clear • Most contraceptives pose little risk to most users’ health • Half of all pregnancies are unintended (3.1 million/yr) • More than 4/10 unintended pregnancies end in elective abortion • Half of unintended pregnancies result from contraceptive failure • 1/3 of all births are unintended Source: Contraceptive Technology (19th ed)

4. Basic types of contraception • Fertility awareness methods • Barrier methods • Situational methods • Spermicides • IUDs • Hormonal contraception • Operative sterilization

5. Fertility Awareness Methods • Also known as Natural Family Planning • Based on understanding ovulatory cycle • Require periods of abstinence & careful recording of events throughout cycle • Cooperation very important • Free, safe, and acceptable to all spiritual beliefs • Require extensive initial counseling • 25% of women will experience unintended pregnancy in first year (typical use; 3-5% in perfect use) • Some women combine with barrier methods (use during fertile periods) and/or combine types of FAM • More difficult when breastfeeding (masks some signs)

6. Fertility Awareness Methods • Basal body temperature (BBT) • Woman takes temp q morning • Must be before any activity • Uses BBT thermometer and same method • Chart for 3-4 months to determine normal pattern • Temp sometimes drops just before ovulation • Almost always rises & remains elevated for several days after • Abstain from intercourse several days before and 3 days after anticipated ovulation

7. Fertility Awareness Methods • Calendar method • Also known as rhythm method • Assumes ovulation takes place 14 days before start of menstrual period • Sperm viable for 48-72 hours, ovum for 24 hours • Record menstrual cycles for 6-8 months to determine shortest & longest cycles • Use record to identify fertile & infertile periods • Least reliable of FAM

8. Fertility Awareness Methods • Cervical mucus method • Also known as Billings or ovulation method • Involves careful assessment of cervical mucus changes throughout cycle • Ovulation mucus clearer, more stretchable (spinnbarkeit), more permeable to sperm • Also ferns when dried on glass slide • Luteal phase mucus thick, sticky, traps sperm (progesterone influence) • Woman abstains from intercourse for one cycle & assesses mucus q D • Peak day of wetness & clear, stretchable mucus is assumed day of ovulation • Can be used by women with irregular cycles

9. Fertility Awareness Methods • Symptothermal method • Multiple assessments made & recorded • Cycle days, coitus, cervical mucus changes, BBT, & secondary changes (increased libido, bloating, mittelschmerz) • Combined approach is more effective

10. Situational contraceptives • Abstinence • Coitus interruptus (withdrawal) • Very unreliable • Demands great self-control • Pre-ejaculate may contain sperm, esp. after a recent ejaculation • Douching after intercourse • Not recommended; may facilitate conception • Lactational amenorrhea method (LAM) • Lactation depresses ovarian function • Exclusive breastfeeding, from the breast (no pumping), in first six months following birth without PP menses is 98% effective • Even more effective if used with other method of contracep.

11. Barrier Methods • Male condom • Female condom • Diaphragm • Cervical cap • Vaginal sponge • Usually used with spermicides • All vaginal barriers may cause increased risk of toxic shock syndrome if used longer than recommended

12. Spermicides • Available as creams, jellies, foams, film, suppositories • May require up to 30 minutes to become effective • Minimally effective if used alone • May cause skin/mucus membrane irritation, allergic reaction

13. Barrier methods • Male condom • Must be used correctly to be effective • No side effects • Inexpensive and easily available • Usually latex, but other types available for allergic • Offers protection from pregnancy and STIs • May also be used for STI protection in oral and anal intercourse

14. Barrier Methods • Female condoms • Thin sheath with flexible ring at each end • May be inserted up to 8 hrs before intercourse • Internal ring functions like diaphragm to cover cervix • External ring covers portion of perineum • Cannot be used with male condom • Slightly less reliable than other barrier methods • More expensive than male condom • Noisy and cumbersome • Available OTC

15. Barrier methods • Diaphragm • Must be used with spermicide • Requires prescription and fitting by HCP • Fits over cervix between pubic symphysis and posterior fornix • Must be inserted before and remain in place at least six hours after intercourse; additional spermicide must be inserted for additional acts of coitus • No hormones involved; may help protect cervix against HPV • Requires comfort with insertion and checking placement • Not recommended for those with hx of recurrent UTI

16. Barrier methods • Cervical cap • Fits over cervix by suction (smaller than diaphragm) • Also used with spermicide • May be left in place 24- 48 hrs • May be more difficult to fit than diaphragm • Requires more dexterity/comfort with body to place correctly

17. Barrier methods • Lea’s shield • Similar to cervical cap, but with valve for passage of secretions & air • One size fits all, but only available by rx in US • Contraceptive sponge • Available OTC, one size (expensive) • Contains nonoxynol-9 • No additional spermicide needed for additional coitus within 24 hrs sponge may be in place • Less effective in parous women

18. Intrauterine contraception • Two forms available in US • Paragard (copper T) • Mirena (releases levonogestrel) • Trigger spermicidal reaction in body, preventing fertilization • Provide long-term, highly effective contraception • Risks include PID, perforation, dysmenorrhea, expulsion • Also may be used as emergency contraception (Paragard only)

19. Intrauterine contraception • Marketed in US to parous women in stable, long-term, monogamous relationships • Inserted into uterus by physician, NP, or CNM • Nursing action: premedicate with ibuprofen to decrease cramping with procedure • Usually inserted either during menses or during first six weeks postpartum (may be inserted any time as long as not pregnant) • String protrudes through cervix into vagina (path for ascending infection if exposed to STI) • Women should check string after each menses • Warning signs: late period, abnormal bleeding (may happen with Mirena), abnormal discharge, s/sx of infection

20. Intrauterine contraception • Paragard • Works by impairing fertilization • May stay in place up to ten years • May cause increased bleeding/cramping with periods • No hormones • Contraindicated in copper allergy • Low daily cost • High user compliance, continuation, & satisfaction • May help prevent endometrial cancer

21. Intrauterine contraception • Mirena • Releases small amount of progesterone (10% of oral contraceptives) • May remain in place for up to 5 yrs • Decreased bleeding, cramping compared to Paragard • May be recommended to women with menorrhagia • Some women stop ovulating while it’s in place • May cease bleeding altogether • May have irregular bleeding, esp. in first few months • Increased risk of ovarian cysts

22. Hormonal contraception • Combined oral contraceptives • Progesterone-only oral contraceptives • Implanted contraceptives • Injected contraceptives • Other hormonal contraceptives • Vaginal ring • Contraceptive patch

23. Hormonal contraception • Combined oral contraceptives (COCs) • Birth control pills with both estrogen & progesterone • Most taken daily for 21 days, with 7 days of placebo or no pill (exceptions: Seasonale,Seasonique, Yaz) • Many formulations--monophasic, multiphasic, different strengths, different progesterones • Side effects differ somewhat based on formulation--see p. 82 • Very effective if used correctly • No protection against STI

24. Hormonal contraception • COCs • Action: • Suppress ovulation through negative feedback to hypothalamic-pituitary axis • Thickening of cervical mucus to prevent sperm entry • May also slow tubal motility, disrupt transport of ova, change function of endometrial vessels, cause endometrial atrophy, and inhibit implantation (not proven)

25. Hormonal contraception • COCs • Contraindications • Pregnancy • Hx of thrombophlebitis/thromboembolic disease • Acute or chronic liver disease or gallbladder disease • Estrogen-depended carcinoma • Undiagnosed menorrhagia • Smoking (esp. if over 35) • Diabetes • HTN • Hyperlipidemia

26. Hormonal contraception • COCs • Caution/relative contraindications • Hx of migraine headaches • Seizure disorder • Depression • Oligomenorrhea • Amenorrhea • Often safer than pregnancy

27. Hormonal contraception • COCs • Noncontraceptive benefits: • Decreased risk of ovarian and endometrial cancer • Relief of menstrual symptoms (e.g. fewer/less painful cramps, lighter flow) • Regulation of irregular menses • Reduced risk of ovarian cysts • Improvement in menstrual migraines • Decreased incidence of ectopic pregnancy • Decreased incidence of benign breast disease & iron deficiency anemia • Some pills decrease PMS/PMDD symptoms (Yasmin & Yaz) • Reduced symptoms of endometriosis, acne, hirsutism

28. Hormonal contraception • Other combined methods • NuvaRing vaginal ring (must be comfortable inserting) • Ortho Evra contraceptive patch • Similar effectiveness, non-contraceptive benefits, contraindications, and side effects as COCs • Patch dispenses higher dose of hormones than COCs, with possible higher risk of venous thromboemobolic conditions • Ring uses progesterone formulation that may increase risk of VTC as well • Neither require daily use • Patch replaced weekly for three weeks, then one week without • Ring left in for three weeks, then one week without

29. Hormonal contraception • Progesterone only pills (mini-pill) • Do not suppress ovulation • Do not affect breast milk supply (good for nursing moms) • Must be taken at same time every day to be effective • Often causes irregular bleeding • Not as effective as combined methods • No risk of venous thromboembolic events

30. Hormonal contraception • Injectable contraception • Combined injection (Lunelle) no longer available in US • Other formulations use progesterone only • Depo-Provera (DMPA-IM 150 mg/1 ml) most commonly used • Given IM q 12 weeks • Depo-subQ provera 104 (DMPA-SC 104 mg/0.65 ml) new formulation • Given SC q 12 weeks

31. Hormonal contraception • DMPA actions & advantages • Works by inhibiting ovulation (suppresses FSH & LH), thickening cervical mucus • Safe for those who can’t take estrogen (e.g. hx of DVT) • Highly effective • Very light to no menstrual periods (but can have irregular bleeding) • New SC formulation less painful, may be self-administered

32. Hormonal contraception • DMPA disadvantages • Most women have irregular bleeding/spotting • Most women gain weight • May increase risk of depression • May decrease bone density • May take up to one year to reverse effects/regain fertility • Must return q 3 mos for injections • No protection from STI

33. Hormonal contraception • Implanted contraception • Norplant no longer available in US • Implanon • Single rod implanted under skin of upper arm • Provides contraception for 3 years • Releases progestin continuously • Extremely effective • Like all progestin-only methods, causes irregular bleeding in many women • Must be inserted by HCP & removed later

34. Emergency contraception • Used after unprotected sex, contraceptive failure, or unsure protection • Should be taken as soon as possible after incident • No medical contraindications except established pregnancy • Most effective in first 72 hours, but still somewhat effective up to 5 days after coitus • Providing EC is the standard of care for women who request it

35. Emergency contraception • Methods • Combined hormonal (Preven, with estrogen & progestin, withdrawn from US market in 2004) • Progestin-only (Plan B, available OTC for those >/= 18, rx for those <18, more effective & better tolerated than Preven) • May use ordinary COCs or minipills to make up dose comparable to Preven or Plan B • Copper IUD insertion (99% effective; can insert up to 7 days after coitus) • Not the same as abortion pill (RU486/mifepristone)!

36. Operative sterilization • Surgical procedures that permanently prevent pregnancy • Very difficult to reverse • Vasectomy and tubal ligation • Extremely effective and cost-effective • Does not protect against STI

37. Operative sterilization • Vasectomy • Relatively minor procedure (safer and less expensive than female sterilization) • Surgical severing of vas deferens • Takes 4-6 weeks/6-36 ejaculations to clear remaining active sperm from vas • Couple needs to use alternate method and bring in semen samples to verify (and recheck at 6-12 months) • SE include pain, infection, hematoma, sperm granulomas, spontaneous reanastomosis

38. Operative sterilization • Female sterilization • May be done with repeat cesarean section or postpartum from vaginal birth • More serious surgery than vasectomy • Complications include coagulation burns to bowel, bowel perforation, pain, infection, hemorrhage, adverse effects of anesthesia • New transcervical method (Essure) does not require opening abdominal cavity, can be done under local anesthesia in physician’s office