Current Contraceptive Choices James L. Hubbard, DO Fellow ACOOG Carolina Ob/Gyn, Rock Hill, SC Chief of Staff, Piedmont Medical Center Board of SC Medical Examiners

Ancient Egypt

 Earliest recorded contraception dates back 3,000 years.

 Smooth pebbles were inserted into the uteri of camels to prevent them from getting pregnant on long trips across the desert.

 Suppositories made from elephant and crocodile dung were inserted prior to intercourse, which has a high concentration of bile salt. Therefore the pH of this dung is the most acidic in the animal kingdom and was both a blocking agent and spermicide.

Other Ancient Cultures

 The Talmud, an ancient Hebrew text, recommends manually removing the semen and douching with soap and vinegar.

 Chinese scrolls recommend dabbing the cervix with a mixture of olive oil and honey, inhibiting both fetal growth and ovulation.

 Ancient Greece used mixture of acacia gum, honey, and seed wool which breaks down to lactic acid.

 In India, wild carrot seed was used as a post-coital contraceptive. Studies have shown that these seeds are a spermicide.

More Recent History

 Condoms date back to 1546 made from everything from animal intestine to animal skins to okra pods. The term condom is thought to have originated from a Dr. Condom, a personal physician of King Charles II.

 Origins of the pill came about by chance. A researcher discovered certain tribes in Mexico were eating a wild yam which seemed to act as a contraceptive. On analysis he was able to extract progesterone from these yams and formulate the first pill.

Condoms

 Male and female.

 Failure rate if used perfectly is 2% in male, 5% in female.

 Typical failure rate is 15% for male, 21% for female.

 Protection against STDs.

Cervical Caps

 Failure rate is 29%.

 Can stay in place up to 48 hours.

 Recommend pap 3 months after initial use due to increase chance of dysplasia which drops off after a year.  Does not protect against STDs.

 May need to be refitted postpartum.

Diaphragms

 Perfect use failure rate 6%, actual 16%.

 Requires fitting, increases UTI.

 Recommended use with spermicide.

 Some protection against STDs.

Spermicide

 Used independently, failure rate 29%.

 Use with condoms no longer recommended.

Combination Pill

 Has been available since the 1960’s. Most contain Ethinyl estrogen and at least 7 different progestins.

Combination Pill

 Mechanism of suppressing ovulation. Perfect use failure rate is 0.3%, actual 6%.

 Advantages: shorter, lighter scheduled menses, no ovulation pain, sexual spontaneity.

 Generic vs. brand name? FDA allows variability in potency in generics of -20% to +25% in dosing of generics .

 Current brand oc available: Loestrin 24 Fe, Lo Loestrin Fe, Beyaz, Natazia, Lybrel, Seasonique.

Controversy around Drospirenone

 Drospirenone: a derivative of spironolactone found in Yasmin, Yaz, and Beyaz.

 Decreasing androgen side effects.

 Hyperkalemia (renal insufficiency, hepatic dysfunction, and adrenal insufficiency).

 Increased risk of blood clots.

Choosing OCs for your patient

 New start (Lo loestrin)  Endometriosis (Seasonque, Lybrel)  Menstrual migraines (Seasinque, Lybrel)  Androgen excess/ PCO (Beyaz)  Breastfeeding (Lo loestrin)  Breakthrough bleeding (higher dose oc, Natazia)  Premenopausal (Lo loestrin)

NuvaRing

® • Very low dose 120  g/day etonogestrel 15  g/day ethinyl estradiol • Flexible transparent ring Outer diameter: 54 mm Cross-sectional diameter: 4 mm • One ring per cycle 3 weeks ring-in 1 week ring-free 54 mm 4 mm

Ortho Evra Patch

 Higher doses of active estrogen in the blood stream than previously thought could increase the chance of DVT.

 Less effective in women 190 lbs or above.

Lunelle

 Monthly injectable combination birth control.

 No longer available since 2002 due to lack of potency assurance.

Pills (Mini Pills)

 Candidates for usage  Breast feeding  History of DVT  Over 35 years of age  Smokers  History of HTN

Depo-Provera injection

 Weight gain  DUB  Fertility post-use  Due to decrease in bone mineral density (BMD) in users, the FDA recommends other forms of bc be used after 2 years of consecutive use if other forms of bc available.

Implanon

 Follow-up to Norplant, which was discontinued in 2002.

 Single implant 4cm long and 2mm wide.

 Placed under the skin of the upper arm.

 Used for 3 years.

ParaGard (Copper T)

 Made from polyethylene with a solid sleeve of copper.

 Introduced in 1984.

 Primary mechanism of action is as a spermicide (releasing toxic cooper ions, causing phagocytosis, and causing crx mucous thickening).

 20% of physicians still believe it has an abortive effect.

 Biggest benefits are its long term use (10 years) and its non-use of steroids.

 PID, pregnancy, perforation.

Mirena

 5-year IUD impregnated with progesterone.

 Similar mechanism of action as the ParaGard with anovulatory effect.

 FDA approved for the treatment of DUB and perhaps premenopausal symptoms.

 Use in nulliparous and young patients.

Failure rates of tubal methods

 Silicon bands 1.8%  Partial salpingectomy 2.0%  Bipolar cautery  S-ring (hulka) clip  Filshie clip 2.5% 3.7% 0.9%

Intrauterine Tubal Occlusion

 Essure   Uses a nickel titanium spring coil with polyethylene fibers. These fibers cause chronic inflammation and scarring. Can be placed hysteroscopically in an outpatient setting with local anesthesia.

  May be preferred in obese pts, pts wishing no scars, and pts with hx of adhesions.

Disadvantages are 3 month waiting period followed by histerosalpingogram, difficult to visualize ostia, perforation of tube, or tubal spasms.

Intrauterine Tubal Occlusion

Intrauterine tubal occlusion

 Adiana  Similar to Essure, is placed hysterscopically, but uses a silicone pellet the size of a grain of rice and long with low level radiofrequency energy to create a superficial lesion in the tube.

 This technique also needs to have a follow up histersalpingogram 3 months post procedure.

Intrauterine Tubal Occlusion

 Progesterone only vaginal ring  Lasts for a full year.

 Gyenfix Copper IUD  6 sleeves of copper on a string embedded in the fundus.

 Lasts 3 years and in use in Europe.

 Fibroplant  Progestin-releasing fiber fixed to the uterine wall.

 Norplant II  Similar to original Norplant but only 2 rods.

 Lasts up to 3 years.

 Contraceptive spray  Progesterone delivered to your forearm.

  Once a month pill  Uses technology similar to EvaMist.

Uses technology similar to Boniva.

 Quinacrine sterilization   Involves insertion of 7 pellets into the uterus with an IUD-type tool.

Repeated 2 to 3 months in a row.

 This causes tubular scarring.

 Currently used in some third world countries, it remains controversial due to lack of knowing if there are any long-term side effects.

The End