Overview of Contraception

Nupur Kumar DO, MPH

May 22, 2006

Drew University PA Program

Facts

In the US there are 63 million women aged 13 – 44 who may potentially use contraception53% of the annual 3 million unwanted pregnancies occur in women who use contraception incorrectly or inconsistentlyChance of pregnancy in 1 year of unprotected intercourse is 85% - available contraceptive methods can decrease this to 0.05%Counseling is the key!

Categories of Contraception

Natural – Rhythm Method

Barrier – Male and Female condom, Spermacide, Sponge, Diaphragm, Cervical Cap

Hormonal – Pill, Patch, Ring, IUD, Depo-Provera Injection

Permanent – Male and Female Sterilization

Emergency Contraception – “morning after” pill

Prior to Initiation

Pap Smear and Pelvic Exam

Negative documented Pregnancy Test

Informed consent with explanation of risks and benefits

Explanation of method use

Natural Family PlanningThe Rhythm Method

Identification of potentially fertile days each cycle when partners may abstain from intercourse

Approximately a period of 6 days based on life spans of sperm (5 Days) and egg (1 Day)

Based on assumption ovulation occurs on cycle day 14 +/- 2 days

9% Pregnancy rate in 1 year of “perfect” use or 26% with typical use

Natural Family PlanningOther Methods I

Cervical Mucus Method Mucus is more abundant and clear as ovulation

approaches; after ovulation mucus is cloudy, thick, scant, or absent.

Basal Body Temperature Body temperature rises 0.4 degrees F around

time of ovulation.

Natural Family PlanningOther Methods II

Symtothermal Method Combination of Cervical Mucus and Basal

Body Temperature methods with checking of symptoms like Mittleschmerz (mid-cycle ovulatory) pain and breast tenderness

Ovulation Prediction Kit - OTC

Male/ Female Condom

Widely and easily availableFailure Rate Perfect Use - 3% Typical Use - 14%

Side Effects – Latex AllergyAdvantages Used in conjunction with another method to

increase efficacy ONLY method decreasing STD/HIV risk

Other Barrier Methods

Spermacides Include gel, cream, foam, film, and suppositories Must insert prior to each act of intercourse 71-82% effective

Vaginal Sponge Wet and insert prior to sexual activity 68 – 91% effective

Diaphragm/Cervical Cap Inserted prior to intercourse (up to several hours) Used in conjunction with foam or gel Needs to be fitted in medical office/clinic 86-96% effective, higher failure rates in patients with a

history of vaginal delivery

Oral ContraceptionCombination Pill

Pill taken at the same time each dayCycle of 28 days – 21 hormone containing pills and 7 sugar or iron pillsFailure Rate Perfect Use 0.1% Typical Use – 5%

Side Effects – breakthrough bleeding, nausea, breast tenderness, headacheAdvantages – decreased menstrual blood loss, decreased dysmenorrhea

Oral ContraceptionProgestin Only

Taken daily within 3 hour periodBased on 28 day cycleFailure Rate Perfect Use – 0.5% Typical Use – 5%

Side Effects – irregular bleeding, breast tenderness, depressionAdvantages – no estrogen, decrease in menstrual blood loss and dysmenorrhea, okay in breast feeding

SeasonaleLong Term Hormonal Contraception

First extended Cycle birth control pill FDA approved in USFour cycles per yearIncreased spotting or breakthrough bleeding in first few monthsPractitioners have been manipulating monthly OCPs for years – this is a fixed package based on the same principle

Disadvantages of Oral Contraception

Forgetfulness – 16% of users are inconsistent in taking the pillEstrogen Effects Avoid in older patients who smoke due to

increased risk of thromboembolic events Increased side effects in estrogen sensitive

patients Spotting/ breakthrough bleeding ( can try pill

with lower dose)

Relationship of Oral Contraception and Cancer

Meta Analysis of 79 long term studies showed excess of 151 cases of breast cancer, 125 of cervical cancer, and 41 of liver cancer. Also showed a decrease in 197 cases of endometrial cancer and 193 of ovarian cancer.NOT statistically significant!Any perceived risk declines after stopping the pill and no difference exists between users and nonusers after 10 years. Chemoprotective effect more prominent in those with family history – 5 year use associated with 50% reduction in uterine and ovarian cancers.

What About Acne?

Most Combination Pills should be beneficial if contain estrogen and progestin with low androgenic activity

Ortho Tri-Cyclen is the only FDA approved pill for the treatment of acne

Oral Contraception Side Effects I

Nausea – subside after few cycles, can change to low estrogen/ progestin only dose

Weight Gain – perceived: minimal or absent

Galactorrhea – suppression of prolactin inhibiting factor, subsides within 3 – 6 months of pill discontinuation

No Menses – change to higher dose estrogen for reassurance

Teratogenicity – no increased risk of congenital malformation if pregnancy occurs

Oral Contraception Side Effects II

Headaches – can take with food, later in the day, or switch to lower estrogen dose

Mood Swings – some relation to vitamin B6 depletion, can supplement or lower estrogen dose

Decreased Libido – due to reduced androgen production, decreased vaginal lubrication may be a factor

Absolute Contraindications to OCP Use

History of thromboemboic events, CVA, Atrial Fibrillation, pulmonary hypertention

Liver Disease

Cancers of Breast and Liver

Pregnancy

Less than 6 weeks postpartum (combo pill only)

Major surgery with prolonged immobilization

Heavy smokers over age 35 (combo pill only)

Hormonal Patch Ortho Evra Patch

Cycle of new patch weekly for 3 weeks then 1 patch free week to allow for menses

Failure Rate Perfect Use – 0.7% Typical Use – 0.9%

Side Effects – similar to OCP, skin irritation, decreased effectiveness in patients weighing > 198 lbs. (90 kg)

Advantages – similar to OCP, less frequent dosing

Hormonal Vaginal Ring NuvoRing

Insert for 3 weeks (continued use) then remove for 1 week for mensesFailure Rate Perfect Use – 0.65% Typical Use – 0.65%

Side Effects – vaginal irritation or discharge, headacheAdvantages – Similar to OCP, less frequent dosing

Intra Uterine Devices (IUD)

2 Available Types Paraguard: copper-containing, 10yrs, works by

inflammation of uterine walls preventing implantation

Mirena: Levonogestral System, 5 yrs, works by releasing hormone

Paraguard: Copper Containing IUD

Procedure to insert: requires consent

Failure Rate Typical Use – 0.6% Perfect Use – 0.8%

Side Effects – heavy menses, dysmenorrhea

Advantages – long acting, nonhormonal, no thinking once in

Disadvantages – increased PID risk with string acting as vector, spontaneous expulsion

MirenaLevonogestral Intrauterine System

Procedure to insert: requires consent

Failure Rate Perfect Use – 0.1% Typical Use – 0.1%

Side Effects - heavy menses, dysmenorrhea

Advantages- no estrogen, easy to use, long term protection

Disadvantages – increased PID risk with string acting as vector, spontaneous expulsion

Depo Provera

Progestin only injection administered once every 3 months; may have delay in returning to fertility

Failure Rate Perfect Use – 0.3% Typical Use – 0.3%

Side Effects – Irregular bleeding or amenorrhea, weight gain, breast tenderness, acne, depression

Black Box Warning – potential of decreased bone mineral density with long term use, must counsel patients about concurrent use of calcium and document!

Advantages – no estrogen, long term

No Longer Used

Lunelle – monthly injection, hormonally based, still available in Mexico

Norplant Series of 5 hormone filled rods placed under

the skin in fan shape Slow hormone release; protection for 5 years No longer placed but patients may present for

removal: scar tissue may cause bleeding

On the Horizon: Male Hormonal Contraception

Currently under investigation

Suppression of gonadatropins and depletion of intratesticular testosterone which together result in arrest of spermatogenisis to induce azo/oligospermia (<1,000,000)

Will likely be a combination of androgens and progestins

Male Permanent Sterilization Vasectomy

Keeps sperm out of ejaculate by blocking vas deferentia: Traditional vs. no scalpel method

Not fully effective for 3 months until existing sperm are “cleared out” of system

Failure Rate 1/1000 in first year

Cost $350 - $500

May be reversible in some cases but difficult and expensive procedure ($5000 - $14000)

Risks: infection, bleeding, granuloma

Female Permanent SterilizationBilateral Tubal Ligation

Surgical closure of bilateral Fallopian Tubes99% effective in the first yearHigher risk of ectopic pregnancy if pregnancy does occur (due to scar tissue)Risks: bleeding, infection, anesthesiaMay be reversible but complicated and expensiveEssure – no incision hysteroscopic method Metal coins inserted to block tubes Confirmed in 3 months by Hysterosalpingogram

Emergency Contraception

Combination of estrogen-progesterone or progesterone aloneGiven up to 72 hours after intercourseSide effects: nausea & vomiting which can be minimized with concurrent administration of an antiemeticNo effect after implantation nor any documented harmful effects to the fetus after emergency contraception has failed

Confidentiality and Minors

Law states a minor may receive contraception without parental consent (Cal. Family Code 6925)Minor is defined as over 12 years of ageStatutory Rape is defined as sexual activity with a partner age over 14 for ages 11 – 13 and over age 21 for ages 14 – 15 even if it is consensual. These are reportable situations.

Case 1

Ms. X is a 37 year old G1P1 who had a baby 2 months ago. She wants to use a birth control method that is safe for her baby as she is breastfeeding. She also wants something that is easily reversible as she wants to have another baby next year. She can’t use condoms as her husband has a latex allergy. What are her options?

Case 2

Mrs. Z is a 40 What are her options? year old G2P2 smoker with moderately controlled hypertention. She wants a safe, long term contraception method as she doesn’t want any more children and her religion is against abortion. She is in a monogamous relationship with her husband of 15 years and has no history of STDs. What are her options?

Questions????