Chapter Thirteen

1. Contraception and Abortion Chapter Thirteen

2. Agenda • Discuss History and Considerations Associated with Methods • Discuss Contraception Methods • Discuss Abortion

3. Class Exercise: Contraception Values Clarification • Complete the handout entitled “Contraception Values Clarification. • After you have completed the handout, discuss your response in small groups.

4. Introduction • Majority of U.S. pregnancies are not planned and most are a result of not using contraception • Factors increasing motivation to use contraception: • good communication with partner, • lower cost, • effectiveness rates, • frequency of intercourse, • motivation to avoid pregnancy, • side effects, • openness about sexuality

5. Contraception in Ancient Times Contraception in the U.S.: 1800s and Early 1900s Contraception Outside the U.S. Contraception: History

6. Contraception in Ancient Times • Ancient Greeks: magic, superstition, herbs • Egyptians: fumigating female genitalia, tampon soaked in herbal liquid & honey, inserting a mixture of crocodile feces, sour milk, & honey • South Africa: insert vegetable seed pods • Africa: insert a grassy cervical plug • Persia: insert alcohol soaked sponges • Greece: insert empty pomegranate halves

7. Contraception in the U.S.: 1800s and Early 1900s • Concern in early 1800s was to curb poverty by controlling fertility • 1873 Comstock laws prohibited dispersing information about contraceptives, including by doctors

8. Contraception use is affected by • Social issues – e.g. desired family size • Economic issues • Knowledge & misinformation • Religion • Gender roles & power – in some areas, men make the contraceptive decisions; for some it is the responsibility of both

9. FDA Approval Process Lifestyle Issues Choosing a Method of Contraception

10. FDA Approval Process • The U.S. Food and Drug Administration (FDA) must formally approve the method • 10-14 year process to develop a new contraceptive drug • Drug company submits a new drug application demonstrating safety in animal tests & a desire to conduct human trials

11. FDA Approval Process • 3 phases • Phase 1: 20-80 volunteers to test effectiveness • Phase 2: several hundred to test effectiveness, side effects, risks • Phase 3: hundreds to thousands are tested for generalization • Animal trials are conducted throughout the process

12. Class Discussion: Lifestyle Issues Associated with Contraceptive • The following factors seem to be associated with choosing a contraceptive method: • Own health & risks • Number of sexual partners • Frequency of intercourse • Risk of acquiring a STI • Responsibility level • Method cost • Advantages & disadvantages of the method • Discuss influence of each.

13. Contraception Methods

14. Barrier Methods: Condoms and Caps • Prevent sperm from entering the uterus • Barrier Methods: • Condoms • The Diaphragm • The Contraceptive Sponge • The Cervical Barriers

15. Condoms • 1850 – latex condoms available in the U.S. • $10-$15/dozen • Non-expired condom is rolled onto an erect penis (foreskin pulled back), ½-inch empty space at the tip • Water-based lubricants for latex condoms • Condom grasped at base when withdrawing • Latex condoms have lower rates of slippage & breakage, and offer better STI protection

16. Condoms • In 1994, female polyurethane/nonlatex condoms were available • $2 each • 7 inches long with 2 flexible rings • Inner ring squeezed and inserted close to the cervix • Outer ring lies outside the vagina • Adequate lubrication is necessary

17. Condoms • Effectiveness rates • Latex condoms: 85-98% • Female condoms: 79-95% • Latex & polyurethane protect against STI transmission • Lambskin condoms block sperm, but contain holes large enough for viruses to pass through • Heat can damage condoms

18. Condoms • Advantages: • STI protection • Encourages male participation • Inexpensive • No prescription necessary • Can reduce premature ejaculation • Can reduce postcoital drip • No medical side effects

19. Condoms • Disadvantages: • Reduces spontaneity • Can reduce sensation • Female condoms can be difficult to use, uncomfortable, noisy • Female & male condoms should never be used together • Popular in some countries, not used in others

20. The Diaphragm • Not widely used, almost 0% in 2002 • Made of latex or silicone • Many sizes and shapes; a fitting by a health care provider is necessary • $20-$35 diaphragm, $13 spermicidal jelly/cream, office visit charge • They can last for many years

21. Diaphragms come in a variety of different shapes and sizes and must be fitted by a health-care provider.

22. The Diaphragm • Diaphragm rim is covered in spermicidal jelly & a tablespoon of jelly is placed in the dome; it is folded in half and inserted into the vagina with the front rim tucked under the pubic bone • It should not be felt & should cover the cervix • It can be inserted up to 6 hours prior to intercourse • Left in for at least 6-8 hours, no more than 24 • After use it is washed with soap & water

23. Instructions for proper insertion of a diaphragm.

24. The Diaphragm • 84-94% effective, lower for those who have given birth • Advantages: • Increases spontaneity • Some STI & PID protection • Reduces risk of cervical dysplasia & cancer • Does not affect hormonal levels • Relatively inexpensive

25. The Diaphragm • Disadvantages: • Physician fitting and prescription • Insertion & removal involves touching the genitals • Increased risk of toxic shock syndrome and urinary tract infection • Postcoital drip • Low usage outside the U.S.

26. The Contraceptive Sponge • The Today contraceptive sponge was taken off the market for a decade due to issues with the manufacturing plant; reintroduced in 2005 • Available over the counter in one size • The sponge covers the cervix & contains spermicide; it blocks, absorbs, & deactivates sperm • One box of 3 sponges is $13

27. The Today contraceptive sponge was back on the market in late 2005 in the United States.

28. The Diaphragm • Sponge is moistened with water to activate the spermicide, folded in half, & inserted to cover the cervix • Can be inserted up to 24 hours in advance, with intercourse occurring as many times as desirable in that time period • Must be left in at least 6 hours after intercourse • 75-89% effectiveness rates

29. Instructions for proper insertion of a contraceptive sponge.

30. The Diaphragm • Advantages: • No prescription necessary • Can have intercourse several times within 24 hours • Increase sexual spontaneity • Do not affect hormonal levels • Disposable

31. The Diaphragm • Disadvantages: • Increased risk of toxic shock syndrome & urinary tract infection • Cannot be used while menstruating • Requires touching of the genitals • High expense if frequently used • Some men can feel it • Low usage rates in other cultures

32. The Cervical Barriers • Thimble-shaped, silicone barriers that fit over the cervix • Block entrance to the uterus & deactivate sperm with the spermicide • Fitting by a health care provider is necessary • Two types: • FemCap • Lea’s Shield

33. The FemCap is a silicone cup shaped like a sailor’s hat that fits securely over the cervix.

34. Lea’s Shield is a silicone cup with a one-way valve and a loop for easier removal.

35. The Cervical Barriers • $15-75 plus cost of spermicide • Left in place for 8 hours after intercourse • After use, it is washed with soap & water • Not to be used during menstruation • 86% effectiveness rate, lower for those who have had children

36. The Cervical Barriers • Advantages: • Left in place for up to 48 hours • Do not affect hormonal levels • Immediately effective • Not permanent • One-way release valve in Lea’s Shield reduces risk of toxic shock syndrome

37. The Cervical Barriers • Disadvantages: • Abnormal Pap smears • Increased risk of urinary tract infections • Increased vaginal odors • Cervical damage • Increased postcoital drip • Fitting is necessary • Some male partners feel it & may dislodge it

38. The Cervical Barriers • Widely used in England • Lea’s Shield is available over the counter in Germany, Austria, Switzerland, & Canada

39. Hormonal Methods for Women: The Pill, the Patch, and More • Changing hormonal levels can deter production of ova, fertilization, and implantation

40. Hormonal Methods for Women: The Pill, the Patch, and More • Combined-Hormone Methods • Birth Control Pills • Hormonal Ring • Hormonal Patch • Progestin-Only Methods • Subdermal Implants • Hormonal Injectibles

41. Combined-Hormone Methods • Combination of estrogen & progesterone • Can repress ovulation and thicken cervical mucus

42. Birth Control Pills • Federally approved in 1960 • Most popular contraceptive in the U.S. and around the world • Most studied type of medication • Combination birth control pills are $12-25 per month • Designed to mimic a menstrual cycle, with 21 days of hormones and one off week • Bleeding is medically induced

43. Birth Control Pills • Some take 2 to 3 packs of active pills in a row to reduce the number of menstrual periods • Seasonale – 84-day active pill with 7-day placebo • Reducing periods can help those with heavy bleeding and cramping • 60% of women prefer to not have a period

44. Birth Control Pills • Increase in estrogen & progesterone prevent the pituitary from sending hormones to ripen the ovaries • Cervical mucus thickens & endometrium buildup is minimal • The body is tricked into thinking it is pregnant • May experience other signs of pregnancy that usually disappear within a few months

45. Birth Control Pills • Initially prescribed a low-dose estrogen pill; increased if breakthrough bleeding occurs • Monophasic pills contain the same dose of hormones in each pill • Multiphasic pills vary in hormone amount • Triphasil pills have 3 sets, each week the hormonal dosage increases • 92-99.7% effective • Need to take it each day at the same time

46. Birth Control Pills • Advantages: • High effectiveness rate • Doesn’t interfere with spontaneity • Reduced menstrual flow, cramps, & PMS • Increased menstrual regularity • Reduced risk of ovarian cysts, uterine & breast fibroids, facial acne, ovarian & endometrial cancers, PID, benign breast disease

47. Birth Control Pills • Disadvantages: • No STI protection • Female’s responsibility; taken daily • Can be expensive • Lower effectiveness if overweight • Not appropriate for smokers • Used throughout the world, although not popular everywhere; some places have it over the counter

48. Hormonal Ring • NuvaRing introduced in 2003 • Plastic ring inserted into the vagina once a month for 3 weeks, removed for 1 week • Affects the body as combination pills do • Body heat & moisture activate a constant dose of estrogen & progesterone; lower dose than pills • $30-35 per month • 99.7% effective

49. The NuvaRing is inserted deep into the vagina; moisture and heat cause it to time-release hormones that inhibit ovulation.

50. Hormonal Ring • Advantages: • High effectiveness • Doesn’t interfere with spontaneity • Reduces menstrual flow, cramps, PMS • Increases menstrual regularity • Protection from ovarian & endometrial cancer and ovarian cysts • Fertility restored upon removal