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CONTRACEPTION

CONTRACEPTION. Objectives. Describe the advantages, disadvantages, failure rates, and complications associated with the following methods of contraception Sterilization Oral steroid contraception Injectable steroid contraception Implantable steroid contraception Barrier methods

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CONTRACEPTION

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  1. CONTRACEPTION

  2. Objectives • Describe the advantages, disadvantages, failure rates, and complications associated with the following methods of contraception • Sterilization • Oral steroid contraception • Injectable steroid contraception • Implantable steroid contraception • Barrier methods • Natural family planning

  3. Abstinence • Mechanism: excludes sperm from female reproductive tract • Effectiveness: 0% failure rate • Ideal for adolescents at high risk for pregnancy and STD’s including HIV • Complications: None

  4. Breastfeeding:Lactation Amenorrhea Method (LAM) • Mechanism: Suckling causes increased prolactin, which inhibits estrogen production and ovulation • 2% typical use failure rate in 1st six mos. • Candidates: • Amenorrheic women < 6 mos post-partum who exclusively breastfeed (90% of nutrition is breast milk) • Women free of blood-borne infections • Women not on drugs that could effect baby Kennedy KI. et al., Contraceptive Technology.2004

  5. LAM Complications • Breastfeeding may increase the risk of mastitis • Return of fertility or ovulation may precede menses. • 33-45% ovulate during 1st 3 months. • Encourage backup form of contraception

  6. Barrier Methods:Male Condoms

  7. Barrier Methods:Male Condoms • Sheaths of latex, polyurethane, or natural membranes that may or may not have spermicide. • Mechanism: Barrier that prevents sperm and infections from entering vagina. • Effectiveness: 15% typical use failure rate. • Candidates: • Couples not in mutually monogamous relationships • Couples in which one partner has an STD/HIV • Couples starting other types of birth control • Couples who can’t use hormonal methods Warner DL, et al. Contraceptive Technology. 2004

  8. Barrier Method:Female Condom • Disposable single use polyurethane sheath placed in vagina. • Flexible movable inner ring at closed end used to insert into vagina. • Flexible outer ring to cover part of the introitus. • Mechanism: Prevents passage of sperm and infections into the vagina. • Failure rate is high at 21% with typical use. Hatcher et al. Managing Contraception.2004

  9. Barrier Method:Female Condom • Candidates the same as for male condoms. • Female condom is reusable only if the partner does not have an STD. • Disadvantages: • Awkward and difficult to place • Most users do not enjoy using female condom (88% of women and 91% of men) • Many couples complain about noise of condom

  10. Female Condom: “Reality”

  11. Barrier Method:Cervical Cap • Thimble- shaped latex rubber device which has an inner ring that provides suction to keep cap on the cervix. • Spermicide is placed inside the cap before being placed on the cervix to kill sperm. • 4 sizes: 22, 25, 28, 31 mm. • Mechanism: barrier that prevents sperm migration into cervical canal

  12. Barrier Method:Cervical Cap • Advantages: • May decrease risk of GC, Chl, and PID • Can be placed 6 hours prior to intercourse • Can remain in vagina up to 48 hours for multiple acts of intercourse • Disadvantages: • No protection against HIV • Poor fit especially in parous women • Failure Rate: As high as 32% in parous women and 16% in nulliparous women • Patient must leave in place at least 8 hours after intercourse before removing

  13. Diaphragm

  14. Barrier Method:Diaphragm • Latex rubber dome-shaped device that covers the cervix • Mechanism: prevents sperm from entering cervical canal • Three types: • Arcing Spring • Coil Spring • Wide Seal

  15. Barrier Method:Diaphragm • Typical use failure rate: 16% in one year • May reduce risk of GC, Chl, PID • Risks: • No protection from HIV • Difficult to place around cervix • May fall out in women with pelvic relaxation • May cause vaginal erosions & infections • May cause reaction in latex allergic • Toxic Shock Syndrome • Urinary Tract Infections

  16. SPERMICIDE • Most common is nonoxynol-9 • Available in creams, films, foams, gels, suppositories, sponges, and tablets • Best when used with barrier methods • 29% typical use failure rate when used alone • Provides no protection against STD’s and HIV

  17. Emergency Contraception (EC) • Any method used after unprotected or inadequately protected sexual intercourse • Three types of EC available in the United States: • High dose progestin only ( Plan B) • Yuzpe method- 13 different combined oral contraceptives (Preven) • Copper IUD ( Paragard) Dickey. Managing Contraceptive Pill Patients, 2002

  18. Emergency Contraception (EC) • Mechanism: Prevents fertilization and implantation. • Counsel patients that this method does not abort a pregnancy that is already implanted • Common in women after an assault or rape • Most women will have a cycle 21 days after completing emergency contraception • If patient does not have a cycle in 21 days, it is important to check a pregnancy test

  19. Emergency Contraception (EC) • High dose progestin-only (Plan B): • 1.5mg Norgestrel at one time or in divided doses. • Divided Dose: 1st dose within 72-120 hours of intercourse. 2nd dose 12 hours later. • One dose: Both tablets within 72-120 hours of intercourse Glaser A. Emergency post-coital contraception, New England Journal of Medicine, 1997.

  20. Emergency Contraception (EC) • Yuzpe Method (Preven) • 100mcg of ethinyl estradiol and 0.50 mg of levonorgestrel in each dose. • 1st dose within 72 hours of intercourse and 2nd dose 12 hours later

  21. Emergency Contraception (EC) • Copper IUD • Place within 5 days of unprotected coitus. • This is usually given to women who plan to use the IUD for long term birth control. • Interferes with implantation after fertilization.

  22. Intrauterine Devices

  23. Copper IUD (Paragard T 380 A) Copper is a spermicide that inhibits sperm motility and acrosomal enzyme action Lasts 10-12 years May increase bleeding and dysmenorrhea Typical use failure rate is 0.8% Mirena (Levonorgestrel) Increases thickness of cervical mucus to inhibit sperm migration Lasts up to 7 years Improves menorrhagia by 90% in most patients Causes amenorrhea in many users Typical use failure rate is 0.1% Intrauterine Devices (IUDs)

  24. IUD • Good for women in mutually monogamous relationships • Risks: • Increased risk of PID within 1st 20 days • Uterine perforation • Fainting with insertion • Expulsion • Unexpected pregnancy following poor placement

  25. Combined Oral Contraceptives(Estrogen & Progestin) • Mechanism: • Blocks ovulation • Thickens cervical mucus • Thins the endometrial lining

  26. Combined Oral Contraceptives(Estrogen & Progestin) • Ethinyl estradiol is the most commonly used estrogen in OCP’s • There are multiple forms of progestins • Monophasic: same amount of hormone in each active tablet • Multiphasic: varying amounts of hormone in each active pill • Most OCP’s have 21 active pills and 7 placebo pills

  27. Combined Oral Contraceptives(Estrogen & Progestin) • Alternate Formulations: • Seasonale: 84 consecutive hormonal pills followed by 7 days of placebo • Ovcon-35: chewable pills • Yasmin:Drospirenone which is anti-androgenic and anti-mineralcorticoid

  28. Combined Oral Contraceptives(Estrogen & Progestin) • Non-contraceptive Uses of OCPs • Dysfunctional uterine bleeding • Dysmenorrhea • Mittelschmerz • Endometriosis prophylaxis • Acne and hirsutism • Hormone replacement • Prevention of menstrual porphyria • Functional ovarian cysts

  29. Combined Oral Contraceptives(Estrogen & Progestin) Advantages: • Less endometrial cancer (50% reduction) • Less ovarian cancer (40% reduction) • Less benign breast disease • Fewer ovarian cysts (50% to 80% reduction) • Fewer uterine fibroids (31% reduction) • Fewer ectopic pregnancies • Fewer menstrual problems            --more regular           --less flow           --less dysmenorrhea           --less anemia • Less salpingitis (pelvic inflammatory disease) • Less rheumatoid arthritis (60% reduction) • Increased bone density • Probably less endometriosis

  30. Combined Oral Contraceptives(Estrogen & Progestin) Disadvantages • Spotting especially in 1st few months • May decrese Libido • Requires daily pill intake • No protection against STD’s and HIV • Possible weight gain • Post-contraception amenorrhea

  31. Combined Oral Contraceptives(Estrogen & Progestin) • Absolute Contraindications: • Thromboembolic disorder (or history thereof) • Cerebrovascular accident (or history thereof) • Coronary artery disease (or history thereof) • Impaired liver function (current) • Hepatic adenoma (or history thereof) • Breast cancer, endometrial cancer, other estrogen-dependant malignancies • Pregnancy • Undiagnosed vaginal bleeding • Tobacco user over age 35

  32. Combined Oral Contraceptives(Estrogen & Progestin) • Relative Contraindications • Migraine headaches, esp. worsening with pill use • Hypertension • Diabetes mellitus • Elective surgery (needs 1 to 3 month discontinuation) • Seizure disorder, anticonvulsant use • Sickle cell disease (SS or sickle C disease (SC) • Gall bladder disease.

  33. Choosing The Right OCP’s • Endometriosis: Choose a pill with a strong progestin to create a pseudo-pregnancy state • Functional Ovarian Cysts: High dose monophasic pill may be more effective • Androgen excess: Choose a pill with high estrogen/progestin ratio to reduce free testosterone and inhibit 5areductase activity • Breastfeeding: Progestin -only pill

  34. Transdermal: Ortho Evra • Delivers 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily • Takes 3 days to achieve a steady state of hormone in the blood stream • Patch is replaced once per week for 3 consecutive weeks • Worn on abdomen, buttocks, upper outer arm, or upper torso • Do not place on the breast

  35. Transdermal: Ortho Evra • Advantages: • Only has to be replaced once per week • May be taken continuously • Disadvantages: • May slip off- provide pt. with an emergency patch • Patch may be less effective in women who are > 198 pounds

  36. Vaginal Contraceptive Ring: NuvaRing • Combined hormonal contraception consisting of a 5.4 cm diameter flexible ring • 15 mcg ethinyl estradiol and 120 mcg of desogestrel • Mechanism: suppresses ovulation • Typical use failure rate: 8%

  37. Vaginal Contraceptive Ring: NuvaRing • Place in vagina and remove after 3 weeks • Allow withdrawal bleeding and replace new ring • Steady low release state • Advantage is patient only has to remember to insert and remove the ring 1x/ month • May be placed anywhere in the vagina

  38. Depo Provera • 150 mg IM every 3 months • Contraceptive level maintained for 14 weeks • Failure Rate: 3% typical use failure rate • Mechanism: • Thickens cervical mucus • Blocks the LH surge • Initiate treatment during the first week of menses

  39. Advantages Long acting Estrogen-free Safe in breast-feeding Can be used in sickle-cell disease and seizure disorder Pt. does not have to take daily Increases milk quality in nursing mothers Disadvantages Irregular bleeding (70% in first year) Breast tenderness Weight gain Depression Slow return of menses after stopping use Decreases HDL cholesterol Depo Provera

  40. Female Sterilization • Interrupts the patency of fallopian tubes- thereby preventing fertilization • Failure rate: Depends on method used -ranges from 0.8-3.7% • May be performed through a mini-laparotomy incision , laparoscopically, or transcervically

  41. Female Sterilization

  42. Male Sterilization

  43. Male Sterilization • Vasectomy: ligate or cauterize the vas deferens • Mechanism: interrupts vas deferens preventing passage of sperm into seminal fluid • May be done under local anesthesia • Cheaper than female sterilization • Failure rate: < 0.15% • Use contraception until completely azospermic for two consecutive sperm counts ( usually takes 12 weeks or 10-20 ejaculations) • Does not affect ability to have an orgasm

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