Contraception (2 lectures)

Who needs contraception
Women spend roughly 30 (or more) years in their childbearing years
Nearly half of all pregnancies that occur in the United States are unplanned/unintended
7 in 10 women are sexually active and do not want to become pregnant, but could if they or their partners fail to use a contraceptive method
The typical US woman wants only 2 children. To achieve this goal, she must use contraceptives for roughly 3 decades.
***Considerations: efficacy, cost, convenience, adverse effects, reversibility

Barrier Methods
1. Spermicide
This is OTC as a jelly, foam, suppositories, film, or cream.
MOA: inactivation of sperm (cell wall destruction)
28% failure rate
Shouldn’t be used alone

Spermicide Advantages
Easy to get as OTC
Inexpensive
some protection from STDs as acting like a barrier
lubricant

Spermicide Disadvantages
allergic reactions possible
unpleasant taste
increased discharge post-coital
suppositories/film require 15-20 minutes to melt

Spermicide additional notes
no clear evidence of birth defects
do not douche 6-8 hours post-coital
must reapply before each act of intercourse
protects for 1 hour after insertion

Barrier Methods
2. Sponge with Spermicide
put into vagina sitting against cervix acting as a barrier in addition to sperm deactivation
failure rate 12-24%
works better with women with smaller cervix (never had children before)

Sponge with Spermicide advantages
OTC although may be difficult to find
cost 3-5$
some degree of protection from STDs as it is a barrier
absorbs excess fluid
lower risk of UTI than diaphragm
TODAY sponge contains nonoxynol 9 as spermicide (activated when moistened with water)

Sponge with Spermicide disadvantages
Allergic reactions could occur (spermicide)
-Slight risk of vaginal infections/toxic shock (menses, first 8 wks post partum)
-May be difficult to get accurate placement, may need re-positioning
-Removal may be difficult – may fragment over time (previously an issue)

Sponge with Spermicide extra notes
previous colonization of s.aureus is a C/I
less effective in women who have already had children or women with uterine prolapse
must assist with placement
should check placement after each intercourse
use condom as backup in first couple months
can leave in place up to 30 hours – disposable

Barrier Methods
3. Condoms
OTC
MOA: mechanical barrier to sperm, may contain spermicide.
Failure rate of 18%

Condoms advantages
OTC
inexpensive 1-2$
**reduces STDs, one of the best for it.
easy to use
male can play active role

Condoms disadvantages
possible allergic reaction to latex (try others like lambskin)
some men may note difficulty maintaining erection
decreased sensitivity
requires interruption of foreplay

Condoms extra notes
may need to add KY or spermicide for lubrication
no vaseline or household products!!!
encourage use with spermicide to increase effectiveness
educate on correct application
withdraw penis after ejaculation to avoid leakage of sperm
use new condom for each act of intercourse
Female Condom:
REALITY
failure rate 21%
not widely used, more costly, and less availability.

Barriers
4. Diaphragm
By prescription only, use with spermicide.
MOA: mechanical barrier to sperm by sitting over the cervix, inactivation of sperm by the spermicide.
Failure rate 12%

Diaphragm advantages
protection from STDS as barrier
250$ for fitting + 100 for device
no systemic side effects
diaphragm lasts years if cleaned and stored properly

Diaphragm disadvantages
Must leave in place 6 hours post-coital, not more than 24 hours
-Possible allergic reaction to latex/spermicide
-Slightly increased risk of urethritis/cystitis from the rim of the diaphragm if it isn’t fitted properly
-Should add spermicide with each successive intercourse
-Possible discomfort/irritation to either partner

Diaphragm extra notes
-Requires office visit for fitting, various sizes available
-Caution if history of vaginal colonization with S. Aureus
-Silicone diaphragm available as alternative to latex
-Life expectancy – Latex 2yrs/silicone 8 yrs
-Abnormal pelvic anatomy a contraindication
-Patient must be comfortable with insertion – first assess pelvic exam/speculum exam.
-Pelvic/introital pain a contraindication
-Should not use prior to 6 week post-partum check
-Should be refit following pregnancy, wt gain/loss, abdominal surgery
-Check diaphragm integrity often – proper care important

Barriers
5. Cervical Cap
Prescription only, use with spermicide
MOA: mechanical barrier to sperm, inactivation of sperm
failure rate 17-23% due to the fact they can order one without a prescription so nobody is fitting it for them.
kind of like diaphragm but fits tighter on the cervix

Cervical Cap Advantages
-Decreases STD/PID incidence
-May be left in place for 48 hours
-Less risk of UTI than with diaphragm due to not having the rim on the outside
-More sexual sensitivity than with other barrier methods
-No need to add additional spermicide for each act of intercourse

Cervical Cap Disadvantages
-Left in place more than 48hrs at a time -> Possible cervical cell changes – Pap needed (?)
-Availability is less
-More difficult to place than other barriers
-One type approved for use in US:
FEMCAP (Silicone) – three sizes
-Not possible to fit all women with this device (anatomical differences)
-Possible allergic reaction to spermicide
-Should be left in place 6 hours following intercourse

Cervical Cap other notes
-Previous vaginal colonization with S. Aureus a contraindication
-Must be comfortable with placement, must be educated on proper placement
-Abnormal paps, cervicitis, recent cervical procedures are contraindication
-Should not be used prior to 6 week post-partum check
-May want to use condom initially until comfortable/confident with use
-Avoid use during menstrual periods

Non-barrier Methods
1. Periodic Abstinence/Fertility Awareness
MOA: avoidance of intercourse during presumed fertile days (calendar, cervical mucus, BBT(basal body temp), ovulation prediction tests
Avoid intercourse 5 days before and 3 days after ovulation.
Failure rate 24%
**14 days before their period starts is when they ovulate.
**Cervical Mucus changes to string like consistency at ovulation.
**Temp: take temp every morning before you do anything else. temp spike of 0.5-1° at ovulation which stays elevated until the period starts. This should be done for a while first.
**Ovulation Prediction Tests – can buy over counter, pee on strips to signal luteal surge. $$$.

Periodic Abstinence/Fertility Awareness Advantages
no side effects, no hormones
acceptable to religious groups who oppose contraception
used more often to plan for pregnancy
encourages communication/understanding among couples.

Periodic Abstinence/Fertility Awareness Disadvantages
some women are unable to identify mucous changes or body temp patterns which cn be affected by illness, stress, etc.
irregular cycles cause difficulty
restricts sexual spontaneity
requires initial and ongoing education
must keep extensive records for several cycles before you can use reliably.

Periodic Abstinence/Fertility Awareness Other Notes
-Patient education & classes available through local organizations and churches
-Must have very motivated couple to be successful
-If pregnancy must be avoided, this may not be the best choice
-May be unreliable, as body temp and cervical mucus can be affected by infection/illnesses, stress, etc.

Non-barrier methods
2. IUD
There are 3 available in the US
Mirena – releases progesterone (levonorgestrel) 5 years
Skyla – releases progesterone (levonorgestrel) 3 years (smaller insertion device??? supposedly)

Paraguard – copper device (no hormones) 10 years

MOA: inhibition of sperm migration, fertilization, or ovum transport
Failure rate less than 1%

IUD advantages
low maintenance – need only check string placement
long term contraception 3-10 years
Mirena improves menstrual symptoms; dysmennorhia, anemia from heavy bleeding.

IUD disadvantages
-Initial cost – Insertion fee $500, device cost of $682 for Paragard, $937 for Mirena (make sure this is covered by their insurance)
-Discomfort during insertion – mild
-Heavier periods – more with paraguard
with increased cramping possible (initially) especially more with women who haven’t had children.
-Irregular bleeding or amenorrhea (Mirena/Skyla)
-Expulsion may occur (rare) – heavy period and IUD falls out
-Risk of perforation of uterus or cervix with placement
-Risk of infection with possibility of secondary infertility or long term pelvic pain (rare – proper selection of patients important)
-If pregnancy occurs, there are risks – consult with ob/gyn

IUD extra notes
-Mirena provides contraception for up to five years; Skyla 3 years
-Paragard is approved for 10 years
-Be familiar with each IUD
-Patient must be educated well – use good documentation/consent!
-Should be inserted gently (never force)
-Use extra caution when inserting into a soft uterus (postpartum, lactating women) – not done prior to 6 weeks postpartum.
-Uterine sound to determine depth prior to insertion
-History of pelvic pathology?
-Nulliparous insertion – patient selection

why no periods with progesterone IUDs
estrogen never there to build the lining, so even though the progesterone is there, there is nothing to shed.

3. ORAL CONTRACEPTIVES
Combination Pills
monophasic/biphasic/triphasic
MOA: suppression of ovulation, changes in cervical mucus and endometrium
Failure rate is 9%, but when used correctly it is < 1%.

Oral Contraceptives – combination pills – advantages
-safe for most women
-Reversible contraception
-Easy to use but must be good pill taker
-Reduction of endometrial and ovarian cancer in pill users
-Reduces menstrual blood loss, anemia, dysmenorrhea
-Some women note relief of PMS
Very predictable menstrual cycle, put on to control.
-Also indicated for endometriosis, fibrocystic breast disease, functional cysts, PCOS, acne
-control of periods

Contraindications:
Thromboembolic events
Liver disease
Estrogen-dependent tumor
Age over 35 and smoker (risk for clotting event increases)
Undiagnosed abnormal menstrual bleeding
Vascular disease, CAD

Precautions:
HTN (BC pill can cause high BP)
Anticonvulsants/other drug interactions
Migraine with aura
Obese, over 35
DM

Oral Contraceptives – combination pills – disadvantages
-Cost is high – $30+ per month (generics much cheaper) (see if insurance covers it)
-Must take pill daily, preferably at same time of day – do it with routine
-No protection from STDs – use condoms too!
-Systemic side effects/physiologic changes, although a lot less now than we did due to lower dose birth control pills.

Oral Contraceptives – combination pills – other notes
Do estrogen pills increase risk of breast cancer? No. However, women who are more at risk for breast cancer? then no, they shouldn’t use it. due to estrogen dependent breast tumors.

Oral Contraceptives – combination pills – extended regimens
-Seasonale/Seasonique – extended regimen oral contraceptive pill – 84 active hormonal pills followed by 7 day placebo or low dose estrogen pill, reduces periods from 12-13 per year to 4 per year; “off label” use of monophasic pills for same effect. Cycle every 3 months.
-Lybrel (5/07) – 365 day continuous regimen – not sure if this is even still out there.
-Higher incidence of breakthrough bleeding with continuous active pills
-Check on insurance coverage – can be costly

Oral Contraceptives – Progestin Only Pills!
These are used much less frequently, for woman who can’t take estrogen.
MOA: changes in cervical mucous, endometrium, and surpassing ovulation.
Failure rate 9%, but when used correctly it is 1-2%

Oral Contraceptives – Progestin Only Pills – advantages
contains NO estrogen (won’t disrupt milk supply in lactation)
safer in smokers

Oral Contraceptives – Progestin Only Pills – disadvantages
-Cost similar to estrogen-containing pills
-Must take pill on daily basis continuously
-Breakthrough bleeding/irregular spotting more common
-Fewer non-contraceptive benefits than combination OCs
-No protection from STDs
-Various types of progestins used (Norethindrone-Micronor, Norgestrel-Ovrette)
-Contraindications: undiagnosed Dysfunctional bleeding; liver disease, current cancer
If you forgot to take one, ok we can catch up, miss more than two days have to start over

Contraceptive Patch – ortho – evra
MOA: suppression of ovulation, changes in cervical mucous and endometrium.
Failure rate 9%, but when used correctly it is 1-2%

Contraceptive Patch – ortho – era: advantages
no daily pill to take
patch changes weekly for three weeks, fourth week is patch free.
same non-contraceptive benefits as oral contraceptive pills as contains both estrogen and progesterone

Contraceptive Patch – ortho – era: disadvantages
-cost, 35$ a month and no generic available
-slightly less effective if weight is > 198lbs based on lower serum estrogen levels
-adhesion problems (recommended to put upper back/torso….waist up)
-no protection from STDs
-systemic side effects – similar to oral contraceptive pills, possible increased risk of venous thromboembolism.

Vaginal Ring
The nova ring
changes in cervical mucous, endometrium, and surpassing ovulation.
Failure rate 9%, but when used correctly it is 1-2%

Vaginal Ring
The nova ring advantages
no daily pill to take
plastic, not latex
Ring left in place for three weeks, then removed for a week
Same non-contraceptive benefits as OCP as contains both estrogen and progesterone…Now saying not sure about this…

Vaginal Ring
The nova ring disadvantages
-Cost – $35 per month
-Placement, expulsion issues, if expelled need to replace within 3 hours
-Underlying vaginal infection?
-Systemic side effects – similar to OCPs, maybe less since it is acting much more locally and not being taken in through the GI tract…side effects may be less since acting locally instead of through the GI tract

DEPO-PROVERA
(MEDROXYPROGESTERONE ACETATE, IM/SUBQ)
MOA: Changes in cervical mucus and endometrium, suppression of ovulation.
Failure rate: 6% Correct use less than (shot given on time) 1%

DEPO-PROVERA
(MEDROXYPROGESTERONE ACETATE, IM/SUBQ)
Advantages
-Injection given at 3 month intervals – $100 + administration fee of $45
-Relatively inexpensive
-Works well for persons unable to take pill on daily basis
-No estrogenic side effects

DEPO-PROVERA
(MEDROXYPROGESTERONE ACETATE, IM/SUBQ)
Disadvantages
-Risk of osteopenia, especially in first 2 years of use; discuss adequate calcium intake
-Irregular bleeding common early, is unpredictable, often leads to amenorrhea after several injections
-Side effects: headache, weight gain, nausea, dizziness…weight gain sticks out the most, it is an appetite stimulant, but if they don’t change their eating habits or activity level they should be ok.
-No protection from STDs
-Possible delayed return to fertility, stop depo, might take a year to get pregnant
-appetite stimulant

DEPO-PROVERA
(MEDROXYPROGESTERONE ACETATE, IM/SUBQ)
Other Notes
-Should establish clinic protocols
-150 mg IM formulation

SUBDERMAL IMPLANTS
Progesterone – Nexplanon
MOA: Changes in cervical mucous, suppression of ovulation
Failure rate less than 1%

SUBDERMAL IMPLANTS
Progesterone – Nexplanon: Advantages
-Offers long term (3 year) contraception
-Reversible upon removal
-No estrogenic side effects
-Need not worry about patient compliance
-Decreased menstrual flow (in some cases) and related anemia
-Appropriate for lactating women

SUBDERMAL IMPLANTS
Progesterone – Nexplanon: Disadvantages
-Initial cost/placement – minor surgical procedure
-May be slightly visible under the skin
-Irregular bleeding patterns – frequent spotting, amenorrhea
-No protection from STDs

SUBDERMAL IMPLANTS
Progesterone – Nexplanon: Other Notes
-Practice insertion kit, video materials patient education available
-Inserted while patient has period, use back up for 7 days
-Side effects may include weight gain, headaches, abdominal pain, acne, mood swings
-Check for drug interactions
-Removal issues? not really. they aren’t in for that long so scar tissue isn’t a big deal, nor is migration.
-Norplant no longer available in US but available in other countries (5 implanted rods)

III. POST-COITAL/EMERGENCY CONTRACEPTION
High dose of estrogen/progesterone within 72 hrs of unprotected intercourse, repeat dose 12 hours later
Ovral or other OCP
Plan B – Levonorgestrel – preferred – better tolerated, more effective
Preven – Estrogen/Progesterone
Period should occur within 7-10 days

MECHANISM: One or more of the following: inhibits ovulation, interference with fertilization or tubal transport, altered endometrial receptivity to implantation, regression of corpus luteum.

EFFECTIVENESS: Up to 85%

POST-COITAL/EMERGENCY CONTRACEPTION advantages
-An option for rape/incest, when barrier or other method fails
-Available without prescription in most locations

POST-COITAL/EMERGENCY CONTRACEPTION disadvantages
-Same oral contraceptive contraindications/side effects
-Not all practitioners comfortable with prescribing

POST-COITAL/EMERGENCY CONTRACEPTION other notes
-Begin patient on appropriate/acceptable method of birth control to avoid future occurrences
-Use anti-emetic prior to dosing if using high dose estrogens

Sterilization
Female Tubal Ligation
MECHANISM: Disruption of tubal patency
EFFECTIVENESS: Failure rate: Less than 1%

Sterilization
Female Tubal Ligation
Advantages
-Most effective form of birth control, short of abstinence
-Compliance not an issue

Sterilization
Female Tubal Ligation
Disadvantages
-Reversibility may be difficult, varies greatly depending on procedure and surgeon
-Requires surgical procedure, anesthesia – conventional laparoscopic procedure
-Complications include hemorrhage, adhesions, bowel damage, uterine perforation, infection
-Newer method of tubal sterilization using micro-coils placed hysteroscopically (ESSURE), 99.8% effective after 4 years

Sterilization
Male Vasectomy
MOA: disruption of vas deferent
Done in office in ~30min
Failure rate: Less than 1%

Sterilization
Male Vasectomy
Advantages
-Most effective form of birth control, short of abstinence
-Can be done in physician’s office, cost $1500

Sterilization
Male Vasectomy
Disadvantages
-Reversibility varies greatly depending on procedure and surgeon
-Complications include hemorrhage, hematoma, infection

***Of utmost importance is thorough patient education. If there are any hesitations, have patient use another method until they are certain of decision.

Reasons persons request reversal:
1. Death of spouse, and remarriage
2. Divorce and remarriage
3. Death of a child

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