Transcript Contraception

Introduction to
Contraception
3,000,000 unintended
pregnancies occur in the
U.S. each year.
50% of U.S. pregnancies
are unintended.
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.
Who needs contraception?
Every reproductive-age woman who is at
risk for “sperm exposure” and who does
not currently desire pregnancy.
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
Don’t be an ass!
Don’t ASSume
anything −
ASK!
“Do you need
contraception?”
not
“What kind of birth
control do you use?
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
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
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
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
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
Contraceptive Options
• Estrogen/progestin
–
–
–
–
oral
transdermal
transvaginal
injectable
• Progestin only
–
–
–
–
oral
injectable
implants
intrauterine
• Emergency contraception
• Non-hormonal IUD
• Barrier methods
– male condom
– female condom
– diaphragm, cervical cap
• Periodic abstinence or fertility
awareness
• Sterilization
– tubal ligation
– transcervical (Essure®)
– vasectomy
Contraceptive Use in the U.S.
among reproductive-age women
30
25
20
15
10
5
Female sterilization
Pill
Male condom
Male sterilization
No method
Withdrawal
Injectable
Periodic abstinence
Diaphragm
IUD
0
Hatcher, R.A. et al. Contraceptive Technology. 18th revised edition, 2004.
Contraceptive Considerations
• 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
“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?
Is it safe?
Voluntary risks in perspective
ACTIVITY
Motorcycling
Automobile driving
Playing football
Canoeing
Age < 35, nonsmoker, OCP use
IUD use
Laparoscopic tubal ligation
Vasectomy
Pregnancy beyond 20 weeks
CHANCE OF DEATH IN A YEAR
1 in 1,000
1 in 5,900
1 in 25,000
1 in 100,000
1 in 200,000
1 in 10,000,000
1 in 38,500
1 in 1,000,000
1 in 10,000
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
METHOD
TYPICAL USE
PERFECT USE
None
85%
85%
Spermicides
29%
18%
Withdrawal
27%
4%
Periodic
abstinence
25%
4%
Diaphragm
16%
6%
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
METHOD
TYPICAL USE
PERFECT USE
Male condom
15%
2%
Pill, patch, ring
8%
0.3%
Depo-Provera
3%
0.3%
Paragard IUD
0.8%
0.6%
Female sterilization
0.5%
0.5%
Male sterilization
0.15%
0.10%
Combination Contraceptives
(Estrogen & Progestin)
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
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
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
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 androgenexcess conditions (such as PCOS)
• Improvement in hot flashes and hormonal fluctuation
symptoms in perimenopausal women
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
weight gain
decreased libido
headaches
breast tenderness
skin hyperpigmentation
Combination Contraceptives
(Estrogen & Progestin)
COMPLICATIONS
• Venous thromboembolism
• Myocardial infarction and
stroke
• Hypertension
DO NOT Rx TO WOMEN
AGE > 35 WHO SMOKE!
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
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
How to Use “The Patch”
•
•
•
•
≈ $40.00 per cycle
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.
Repeat this pattern every 4 weeks.
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
“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
Progestin-Only Contraceptives
Progestin-Only Contraceptives
Mechanisms of action:
• Inhibition of ovulation
• Prevention of sperm penetration by thickening and
decreasing the quantity of cervical mucus
• Endometrial atrophy
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
Progestin-Only Contraceptives
DISADVANTAGES OF ALL METHODS
• Menstrual cycle disturbances
• Weight gain
• Depression
• Lack of protection against STIs
Progestin-Only Pills
Cycle consists of 28 active pills;
there is no “placebo week”
Vulnerable efficacy! Each pill
must be taken on time at 24hour intervals.
BRAND NAMES:
Micronor
Nor-QD
Ovrette
≈ $45.00 per cycle
Compatible with breast-feeding
& recommended in
combination with lactational
amenorrhea.
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 longterm use
Depo-Provera = depot
medroxyprogesterone
acetate 150 mg IM q 12
weeks
Progestin Implants
Norplant (off
the market)
Implanon 
FDA-approved
& coming soon
Advantages:
• highly effective
• eliminate “user error”
• long-term
• reversible
Disadvantages:
• high initial cost
• insertion & removal require
specialized training
• cannot be easily
discontinued
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
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
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 contraceptives, 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.
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
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
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
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
Barrier Methods
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
Male Condoms
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
FAILURE RATES:
perfect use
2%
typical use
15%
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
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
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
Spermicides
Mechanism of action:
Nonoxynol-9 is a surfactant that
destroys the sperm cell membrane.
Advantages:
• available without Rx
• easy to use, can use intermittently
without advance planning
FAILURE RATES
Disadvantages:
(when used alone)
• no protection against STIs
perfect use
18%
• frequent (> 2x/day) use may cause
typical use
29%
tissue irritation that could increase
$10-15 per package
susceptibility to HIV
Fertility Awareness /
Periodic Abstinence
Mechanism of action:
users identify the days in
each menstrual cycle
when intercourse is most
likely to result in
pregnancy, then abstain
from intercourse or use a
barrier method during the
“fertile window”
Fertility Awareness /
Periodic Abstinence
Methods:
• ovulation method (assessment of
cervical mucus)
• symptothermal methods (basal
body temperature + mucus)
• calendar rhythm method
• standard days method
(CycleBeads)
• Creighton Model FertilityCare
System
Fertility Awareness /
Periodic Abstinence
Advantages:
• No hormones
• No side effects
• Enables a woman to understand
her body’s cycles
• Promotes cooperation between
partners
• Can also be used to achieve
pregnancy or to identify
infertility problems
• The only method approved by
the Catholic Church
Disadvantages:
• Methods require varying amounts
of training & cost
• Detracts from spontaneity, causes
friction between partners if not in
agreement
• Difficult to use if:
− recent childbirth
− breastfeeding
− recent menarche
− approaching menopause
− recent discontinuation of a
hormonal method
− irregular cycles
− unable to interpret fertility signs
Sterilization
Sterilization is chosen by 39% of couples who use contraception in the
U.S.
28% of reproductive age women undergo tubal ligation and 10% of men
undergo vasectomy.
Tubal Ligation
Mechanism of action: the
fallopian tubes are cut or
mechanically blocked to
prevent the sperm and ovum
from uniting
Can be performed laparoscopically or through a
suprapubic “mini-laparotomy”
incision (or at C-section)
Failure rate: 0.5%
Tubal Ligation
Advantages:
• permanent
• highly effective
• safe
• quick recovery
• lack of significant long-term side
effects
• cost effective
• partner cooperation not required
• not coitus-linked
Disadvantages:
• possibility of patient regret
• difficult to reverse
• future pregnancy could require
assistive reproductive technology (such as IVF)
• more expensive than vasectomy
Transcervical Sterilization
Essure™ Mechanism of
Action:
Using a hysteroscopic approach, one
Essure micro-insert is placed in the
proximal section of each fallopian
tube lumen. The micro-insert expands
upon release, acutely anchoring itself
in the fallopian tube.
The micro-insert subsequently elicits
a benign tissue response. Tissue ingrowth into the micro-insert anchors
the device and occludes the fallopian
tube, resulting in sterilization.
FAILURE RATE:
0.2% after 3 years
Vasectomy
Mechanism of action: each
vas deferens is cut to
prevent the passage of
sperm into the ejaculated
seminal fluid
FAILURE RATE:
perfect use 0.10%
typical use 0.15%
Vasectomy
Advantages:
• permanent
• highly effective
• safe
• quick recovery
• lack of significant long-term side
effects
• cost effective; less expensive
than tubal ligation
• no partner cooperation needed
• removal of contraceptive burden
from the woman
Disadvantages:
• reversal is difficult, expensive,
often unsuccessful
• patient may regret decision
• not effective until all sperm
cleared from the reproductive
tract
• no protection from STIs
≈ $500.00
Emergency Contraception
Definition: emergency contraceptives are methods a
woman can use after intercourse to prevent pregnancy
Methods:
• Plan B − the only dedicated product marketed
specifically for emergency contraception
• Off-label use of progestin-only contraceptive pills
• Off-label use of combination estrogen-progestin pills
• Insertion of a copper-releasing IUD
Emergency Contraception
Indications for use:
• contraceptive failure (condom
broke, pills forgotten)
• error in withdrawal or periodic
abstinence
• rape
• any unintended “sperm exposure”
Contraindications:
• pregnancy
EC could prevent about ½ of unintended pregnancies −
1.5 million pregnancies in the U.S. every year.
Emergency Contraception: Plan B
Contents: 750 µg levonorgestrel
per pill
If taken within 72 hours as
directed, Plan B reduces the risk
of pregnancy from a single act of
intercourse by 89%.
≈ $35.00 per pack
Directions:
Take the first tablet as soon as
possible within 72 hours after
unprotected intercourse.
Take the second tablet 12 hours
later.
The sooner Plan B is taken, the
better. It can be taken up to 120
hours after intercourse.
Emergency Contraception: Plan B
Mechanisms of Action
• Disruption of development
• Disruption of development
and maturation of ovarian
of the zygote, morula, &
follicles
blastocyst
• Disruption of egg maturation • Impaired transport in the
and ovulation
fallopian tube & uterine
cavity
• Interference with corpus
luteum function
• Interference with
development of the
• Alteration of cervical mucus,
endometrium to impede
blocking sperm transport
implantation
When does pregnancy start???
The American College of
Obstetricians and Gynecologists
(ACOG), the Food and Drug
Administration (FDA), and the
National Institutes of Health (NIH)
have defined implantation as the
beginning of pregnancy.
If fertilization has occurred,
implantation starts about 7 days
after ovulation.
Plan B disrupts the events leading up to implantation.
After implantation, it has no effect.
Emergency Contraception: Plan B
Is Plan B an “abortion pill?”
No. The oral abortifacient is RU-486 (mifepristone,
Mifeprex) which is an antiprogestin that blocks the
effects of progesterone by binding to its receptors. It
is usually given in combination with misoprostol
(Cytotec) to medically induce abortion in gestational
ages up to 49 days after LMP.
If implantation has occurred, Plan B will do nothing.
Emergency Contraception
Alternatives to Plan B:
20 tablets of a progestin-only pill (e.g., Micronor) x 2 doses,
12 hours apart
2 doses of a combined estrogen-progestin pill, 12 hours apart
Alesse
5 pink pills (100 µg EE + 500 µg levonorgestrel)
Triphasil
4 yellow pills (120 µg EE + 500 µg levonorgestrel)
Ovral
2 white pills (100 µg EE + 500 µg levonorgestrel)
If you give estrogen, give an antiemetic also!
Emergency Contraception
Standards of care:
• providing information
• providing post-coital
treatment
• providing advance Rx
“Every woman, every visit.”
www.NOT-2-LATE.com
1-888-NOT-2-LATE
− ACOG
Go get΄em!