Overview of Contraception Nupur Kumar DO, MPH May 22, 2006 Drew University PA Program
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????