Introduction to Contraception

1. Introduction to Contraception

2. 3,000,000 unintended pregnancies occur in the U.S. each year. 50% of U.S. pregnancies are unintended.

3. Women’s Reproductive Life Scan The reproductive years are defined as ages 15-44. Of the 39 years spent in the reproductive stages of life, women spend an average of 20 years trying to avoid pregnancy.

4. Who needs contraception?Every reproductive-age woman who is at risk for “sperm exposure” and who does not currently desire pregnancy.

5. Who does not need contraception? women who self-identify as lesbian celibate women women who do not want contraception − for any reason! women who desire pregnancy

6. Don’t be an ass! Don’t ASSume anything − ASK! “Do you need contraception?” not “What kind of birth control do you use?

7. What is the “best” contraceptive method? • The best contraceptive method for an individual woman is a method that is: • medically appropriate • effective in preventing pregnancy • used consistently and correctly • satisfactory to the woman at her stage of life

8. Life Stage: Menarche to First Intercourse • Fertility goals: • postpone pregnancy • preserve future fertility • Sexual behavior: • no intercourse yet • possibly experimenting with kissing, petting, etc. • Contraceptive need: • education

9. Life Stage: First Intercourse to First Birth • Fertility goals: • postpone pregnancy • preserve future fertility • Sexual behavior: • ? multiple partners • frequent intercourse • spontaneous, unpredictable intercourse • Contraceptive needs: • efficacy • reversibility • not coitus-linked • STI prevention

10. Life Stage: First Birth to Last Pregnancy • Fertility goals: • space pregnancies • preserve future fertility • Sexual behavior: • one partner (?) • moderate to low frequency of intercourse • predictable intercourse • Contraceptive needs: • efficacy • reversibility • ? OK if coitus-linked • ? need for STI prevention

11. Life Stage: Last Birth to Menopause • Fertility goals: • no further pregnancies • no need to preserve fertility • Sexual behavior: • one partner (?) • low to moderate frequency of intercourse • predictable intercourse • Contraceptive needs: • efficacy • may be irreversible • ? OK if coitus-linked • ? need for STI prevention

12. Estrogen/progestin oral transdermal transvaginal injectable Progestin only oral injectable implants intrauterine Non-hormonal IUD Barrier methods male condom female condom diaphragm, cervical cap Periodic abstinence or fertility awareness Sterilization tubal ligation transcervical (Essure®) vasectomy Contraceptive Options • Emergency contraception

13. Contraceptive Use in the U.S.among reproductive-age women Hatcher, R.A. et al. Contraceptive Technology. 18th revised edition, 2004.

14. Effectiveness Frequency of intercourse Sexual behavior Desire for future fertility Cost of method Side effects Contraindications Noncontraceptive benefits Patient’s perceptions and misconceptions Patient’s health status and medical conditions Contraceptive Considerations

15. “The great question that has never been answered, and which I have not yet been able to answer, despite my thirty years of research into the feminine soul, is ‘What does a woman want?’”− Sigmund Freud What does a woman want from a contraceptive? • Is it safe? • Does it work? • Will my partner accept it? • Can I afford it? And some women will ask − • Does it cause an abortion?

16. Is it safe?Voluntary risks in perspective ACTIVITYCHANCE OF DEATH IN A YEAR Motorcycling 1 in 1,000 Automobile driving 1 in 5,900 Playing football 1 in 25,000 Canoeing 1 in 100,000 Age < 35, nonsmoker, OCP use 1 in 200,000 IUD use 1 in 10,000,000 Laparoscopic tubal ligation 1 in 38,500 Vasectomy 1 in 1,000,000 Pregnancy beyond 20 weeks 1 in 10,000

17. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception in the United States

18. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception in the United States

19. Combination Contraceptives (Estrogen & Progestin)

20. Combination Contraceptives (Estrogen & Progestin) • Ingredients: • Estrogen (ethinyl estradiol) 20-50 mcg • Progestin (varying forms, doses, potency) • Mechanisms of action: • Suppression of ovulation • Thickening of cervical mucus • Thinning of endometrium • Slowing of tubal and endometrial motility

21. Combination Contraceptives (Estrogen & Progestin) GENERAL ADVANTAGES • Highly effective in preventing pregnancy when taken correctly • Not related to coitus • Rapid return to fertility after discontinuation • Very safe when prescribed for appropriate users • Can be used throughout the reproductive years

22. Combination Contraceptives (Estrogen & Progestin) HEALTH BENEFITS • Fewer pregnancies = fewer maternal deaths • Reduction in risk of ectopic pregnancy • Decrease in dysmenorrhea • Decrease in menorrhagia • Reduction in PMS symptoms • Elimination of Mittelschmerz • Decreased anovulatory bleeding • Fewer ovarian cyst problems

23. Combination Contraceptives (Estrogen & Progestin) HEALTH BENEFITS • Endometrial and ovarian cancer risk reduction • Decreased risk of benign breast conditions • Suppression of endometriosis • Improvement of androgen-sensitivity or androgen-excess conditions (such as PCOS) • Improvement in hot flashes and hormonal fluctuation symptoms in perimenopausal women

24. Combination Contraceptives (Estrogen & Progestin) GENERAL DISADVANTAGES • Must be taken consistently and correctly to be effective • Storage, access, lack of privacy • Can interfere with lactation • No protection against STIs • Common side effects include: nausea, vomiting headaches weight gain breast tenderness decreased libido skin hyperpigmentation

25. Combination Contraceptives (Estrogen & Progestin) COMPLICATIONS • Venous thromboembolism • Myocardial infarction and stroke • Hypertension DO NOT Rx TO WOMEN AGE > 35 WHO SMOKE!

26. Combination Contraceptives (Estrogen & Progestin) CONTRAINDICATIONS • Personal history of thrombosis; known clotting disorder (factor V Leiden mutation, etc.) • Personal history of stroke or MI • Labile hypertension • Estrogen-sensitive malignancy (such as breast CA) • Active liver disease • Migraines with focal neurologic symptoms

27. How to Take Birth Control Pills The 28-day pack contains 21 active pills + 7 placebo pills. Getting started: • “First day” start • Sunday start • “Quick Start” Continuing: one pill per day, every day. Withdrawal bleeding will occur during the placebo week. ≈ $35.00 per cycle

28. How to Use “The Patch” Each patch is worn for 7 days. • Getting started: apply the first patch to clean, dry skin anywhere except the breast. • On the same day of the 2nd week, remove the 1st patch and apply a new one to a different site. • On the same day of the 3rd week, replace patch again. • On the same day of the 4th week, remove the last patch. Do not apply a patch for 1 week. Withdrawal bleeding will occur. ≈ $40.00 per cycle Repeat this pattern every 4 weeks.

29. How to Use “The Ring” • Getting started: squeeze the ring between your thumb and index finger. Insert it in the vagina. • Leave the ring in place for 21 days (3 weeks). • At the end of the 21 days, remove the ring by inserting a finger in the vagina and pulling it out. • Discard the ring and wait 7 days. Withdrawal bleeding will occur. • Repeat the pattern (3 weeks in, 1 week out) ≈ $40.00 per cycle

30. “Extended Use” Regimens Monthly withdrawal bleeding is NOT necessary! Seasonale provides 84 active pills followed by 7 placebo pills for 4 “periods” a year. Any monophasic pill, the patch, or the ring can be used on an extended basis. ≈ $100.00 per pack

31. Progestin-Only Contraceptives

32. Progestin-Only Contraceptives Mechanisms of action: • Inhibition of ovulation • Prevention of sperm penetration by thickening and decreasing the quantity of cervical mucus • Endometrial atrophy

33. Progestin-Only Contraceptives ADVANTAGES OF ALL METHODS • No estrogen • Reversible • Amenorrhea or scanty bleeding • Improvement in dysmenorrhea, menorrhagia, PMS, endometriosis symptoms • Decreased risk of endometrial or ovarian cancer • Decreased risk of PID • Compatible with breast-feeding

34. Progestin-Only Contraceptives DISADVANTAGES OF ALL METHODS • Menstrual cycle disturbances • Weight gain • Depression • Lack of protection against STIs

35. Progestin-Only Pills Cycle consists of 28 active pills; there is no “placebo week” Vulnerable efficacy! Each pill must be taken on time at 24-hour intervals. Compatible with breast-feeding & recommended in combination with lactational amenorrhea. BRAND NAMES: Micronor Nor-QD Ovrette ≈ $45.00 per cycle

36. Depo-Provera Advantages: • highly effective • discreet & private • use not linked to coitus • requires user to “remember” only 4 times a year Disadvantages: • weight gain • impossible to discontinue immediately • delayed return to fertility • adverse effects on lipids • decreased bone mineral density with long-term use Depo-Provera = depot medroxyprogesterone acetate 150 mg IM q 12 weeks

37. Progestin Implants Advantages: • highly effective • eliminate “user error” • long-term • reversible Disadvantages: • high initial cost • insertion & removal require specialized training • cannot be easily discontinued • Norplant (off the market) Implanon  FDA-approved & coming soon

38. Intrauterine Devices (IUDs) GENERAL ADVANTAGES • highly effective, no “user error” • convenient • long-lasting • reversible • discreet • cost-effective in the long run • low incidence of side effects • independent of coitus

39. Intrauterine Devices (IUDs) GENERAL DISADVANTAGES: • menstrual problems • discomfort with insertion • expulsion of the device • perforation of the uterus • requires office visit with trained professional for insertion & removal • high initial cost • no protection from STIs

40. Intrauterine Devices (IUDs) MYTH: IUDs increase the risk of PID. FACT: IUDs have no effect on the risk of upper genital tract infection. STIs cause PID − IUDs do not. MYTH: IUDs cause abortions. FACT: IUDs prevent fertilization and thus are true contra-ceptives, not abortifacients. MYTH: IUDs increase the risk of ectopic pregnancy. FACT: IUDs reduce the risk of ectopic pregnancy because IUDs prevent all types of pregnancy. MYTH: Only parous women are IUD candidates. FACT: Nulliparous women are more likely to expel the IUD and insertion through the cervical os can be more difficult.

41. Copper T 380A IUD (Paragard) Contents: polyethylene, copper wire, & barium sulfate for X-ray visibility, white threads Mechanism of action: Causes increase in uterine & tubal fluids containing copper ions, enzymes, prostaglandins, and macrophages that impair sperm function and prevent fertilization

42. Copper T 380A IUD (Paragard) ADVANTAGES SPECIFIC TO THE Cu380A: • Can remain in place for up to 10 years • Nonhormonal • Normal menstrual pattern continues DISADVANTAGES SPECIFIC TO THE Cu380A: • Can cause heavier menses with more severe cramping, especially in the first few cycles

43. Levonorgestrel Intrauterine System (LNG-IUS) (Mirena) Contents: polyethylene, levonorgestrel, barium sulfate, dark-colored threads Mechanisms of action: • thickening of cervical mucus • inhibiting sperm capacitation & survival • suppressing the endometrium • suppression of ovulation due to systemic absorption of progestin

44. Levonorgestrel Intrauterine System (LNG-IUS) (Mirena) ADVANTAGES SPECIFIC TO THE MIRENA: • can remain in place for up to 5 years • protective against endometrial cancer • reduces menstrual bleeding by 90%; 20% of users become amenorrheic • low incidence of progestin side effects (only 10% systemically absorbed) DISADVANTAGES SPECIFIC TO THE MIRENA: • irregular bleeding, especially during the first 6 months

45. Barrier Methods

46. Male Condoms Mechanism of action: acts as a physical barrier; prevents pregnancy by blocking passage of semen Types available: • latex (natural rubber) • natural membrane (lamb intestine) • polyurethane • spermicidal 50¢-$1.00 each

47. ADVANTAGES: • male participation • no Rx needed • very inexpensive • effective in preventing pregnancy when used correctly • minimal side effects • provide STI protection (except for lambskin) DISADVANTAGES: • reduce sensitivity • reduce spontaneity • erection problems • lack of cooperation • embarrassment about purchasing • not very effective with “typical use” • latex allergy Male Condoms

48. Male Condoms MINIMIZING USER ERROR • Use with every act of intercourse • Use “from start to finish” • Unroll condom onto penis (do not unroll first; do not test by filling with air or water first) • Hold rim during withdrawal to prevent slippage or leakage • Have several condoms available • Use appropriate lubricants • Store condoms correctly FAILURE RATES: perfect use 2% typical use 15%

49. Female Condoms • No Rx needed • One-time use • Includes a lubricant • Spermicide not recommended • Can be inserted up to 8 hours prior to intercourse; can remain in place for up to 8 hours • Protects against STIs • Failure rates: perfect use 5% typical use 21% ≈ $3.50 each

50. Diaphragms & Cervical Caps Mechanism of action: • physical barrier to prevent sperm from reaching the cervix • chemical to kill sperm (spermicide) Advantages: • no hormones • virtually no side effects Disadvantages: • require professional fitting • require user skill and commitment • less effective than most other methods