CHAPTER 10 Family Planning ’S GYNECOLOGY NOVAK OBGY R1 Lee Eun Suk
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Transcript CHAPTER 10 Family Planning ’S GYNECOLOGY NOVAK OBGY R1 Lee Eun Suk
NOVAK’S GYNECOLOGY
CHAPTER 10 Family Planning
OBGY R1 Lee Eun Suk
Family Planning
The rapid growth of the human population in this century
threatens the survival of all
At this present rate, the population of the world will double
in 47 years
That of many of the poorer countries of the world will double
in about 20 years
Family Planning
For the individual and for the planet, reproductive health
requires careful use of effective means
Prevent both pregnancy and sexually transmitted diseases
The contraceptive choices made by American couples in 1995
For couples older than 35 years of age
Sterilization is the number one choice
For younger couples
Oral contraceptives (OCs) are the most used methods
The condom ranks second
T10.1
Family Planning
Abortion is an obvious indicator of unplanned pregnanacy
Abortion ratios by age group indicate that the use of abortion
Greatest for the youngest women
Least for women in their late 20s and early 30s
Family Planning
Young people are much more likely to experience
contraceptive failure
Their fertility - greater than of older women
More likely to have intercourse without contraception
Efficacy of Contraception
Factors affecting whether pregnancy will occur
fecundity of both partners
timing of intercourse in relation to the time of ovulation
method of contraception used
intrinsic effectiveness of the contraceptive method
correct use the method
A pregnancy rate per year can be calculated using the Pearl
formula
The
The
The
The
The
Dividing the number of pregnancies by the total number of months
contributed by all couples, then multiplying the quotient by 1,200
Rates of pregnancy with different methods are best calculated
by reporting two different rates derived from multiple studies
T10.2
Safety
Some contraceptive methods have associated health risks
; Areas of concern are listed in Table 10.3
Most methods provide noncontraceptive health benefits in
addition to contraception
Oral contraceptives reduce the risk for ovarian and endometrial
cancer and ectopic pregnancy
Barrier methods and spermicides provide some protection against
STDs, cervical cancer, and tubal infertility
T10.3
Cost
Intrauterine devices (IUDs) & subdermal implants
Expensive initial investment
Prolonged protection for a low annual cost
Sterilization & the long-acting methods
The least expensive over the long term
T10.4
Nonhormonal Methods
Coitus Interruptus
Lactation Amenorrhea
Periodic Abstinence or Natural Family Planning
Condoms
Vaginal Spermicides
Vaginal Barriers
Intrauterine Devices
Coitus Interruptus
Withdrawal of the penis from the vagina before ejaculation
Advantages
Immediate availability
No cost
Reduced the risk for STDs
Failure rate ( reported by The Oxford Study )
6.7 per 100 woman-years
The penis must be completely withdrawn both from the vagina
and from the external genitalia
Lactation Amenorrhea
Ovulation is suppressed during lactation
The suckling of the infant
prolctin levels↑
gonadotropin-releasing hormone (GnRH)↓
luteinizing hormone (LH)↓
follicular maturation↓
Another method of contraception should be used from 6 months
after birth, or when menstruation resumes
→
→
→
→
Progestin only OCs, implants, injectable contraception
Barrier methods, spermicides, IUDs
The risk for the breast cancer↓
Periodic Abstinence or Natural Family Planning
Couples attempt to avoid intercourse during the fertile period
around the time of ovulation
A variety of methods
The calendar method
The mucus method (Billings or ovulation method)
The least effective
To predict the fertile period by feeling the cervical mucus
The symptothermal method
The first day of abstinence is predicted either from the calendar,
by subtracting 21 from the length of the shortest menstrual cycle
in the preceding 6 months
The end of the fertile period – by use of basal body temperature
Periodic Abstinence or Natural Family Planning
Efficacy
3.1% probability of pregnancy in 1 year for the small proportion of
couples who used the method perfectly
86.4% for the rest
Vaginal infection increase vaginal discharge
↑ Complicating the use of the method
Accurate advance prediction of the time of ovulation
↑ Facilitate both the use & efficacy
Periodic Abstinence or Natural Family Planning
Risks
Conceptions resulting from intercourse remote from the time of
ovulation
↑ Spontaneous abortion
than contraceptions from midcycle intercourse
→ Malformations are not more common
Condoms
Latex rubber condoms
1840s due to vulcanization
Hold the seminal fluid → preventing its position in the vagina
Prelubricated with the spermicide
↑ More effective
The risks for condom breakage
About 3%
Condoms
Sexually Transmitted Diseases
Latex condoms and other barrier methods
↓ the risk for STDs
↓ Gonorrhea, ureaplasma, and PID and its sequelae (tubal infertility)
Chlamydia trachomatis , herpes virus type 2,HIV, and hepatitis B
→ did not penetrate
Some protection from cervical neoplasia
Latex allergy could lead to life-threatening anaphylaxis
Nonlatex condoms of polyurethane and Tactylon are now available
Condoms
Female Condoms
Vaginal pouches made of polyurethane are available
Efficacy trials
The pregnancy rate : only 2.6%
No signs of trauma, and the bacterial flora is not changed
Vaginal spermicides
Nonionic surface-active detergents that immobilize sperm
Aerosol foams provided rapid dispersal throughout the vagina
the best protection
Nonoxynol-9
↓ the risk for bacterial vaginosis and other STDs, including HIV
Toxic to the lactobacilli that normally colonize the vagina
vaginal colonization with bacterium Escherichia coli
Concerns about possible teratogenicity
No greater risk for miscarriage, birth defects, or low birth weight
Vaginal Barriers
Vaginal diaphragm, cervix cap, vault cap, vimule (Fig. 10.4)
They are safe
The noncontraceptive benefit
Protection from STDs, tubal infertility & cervical neoplasia
F10.4
Vaginal Barriers
Diaphragm
Circular spring covered with fine latex rubber (Fig 10.5)
Coil-spring & flat –spring → flat oval compressed for insertion
Proper fitting & proper use are key to its effect
Spermicide is always prescribed for use
Fig 10.5
Risks
↑The risks for bladder infection
Relative risk : 1.42, 2.83, and 5.68 for use 1, 3, or 5days in a week
→ Smaller-sized, wide-seal diaphragm or cervical cap
An study comparing cases of toxic shock with controls
No increased risk from diaphragm use
Cervical caps
Much smaller than the diaphragm
Does not contain a spring in the rim
Covers only the cervix with spermicide
Efficacy
A first-year pregnancy rate of 11.3 per 100 women
Near perfect use → a first-year pregnancy rate of 6.1 per 100
The cap worn for more than 72 hours → pregnancy rate ↑
The failure rates with “perfect use” → higher than the diaphragm
Parous women more failures than nulliparous women
Fitting Cervical caps
The cervical size is estimated and palpation
The cap is inserted by compressing it between finger and thumb
and placing it through the introitus, dome outward
Before use, the cap is one-third filled with spermicidal jelly or
cream
Cervical caps - Risks
Negative cervical cytology progressed to dysplasia in 4%
Other studies - not found this effect
In contrast, Koch - to be protected from dysplasia
Not associated with cystitis
Toxic shock – not reported
Intrauterine Devices
Very important worldwide but play a minor role in contraception
for the U.S.
High-dose copper IUD : TCU380, or ParaGard
Safe, long-term contraception with effectiveness equivalent to
tubal sterilization
The third copper IUDs
T380A (ParaGard) : the progesterone-releasing T (Progestasert)
Bands of copper on the cross arms of the T
Copper wire around the stem
Total surface area of 380 mm of copper
Levonorgestrel-releasing T (Mirena)
Mechanism of Action
Formation of “biologic foam” within the uterine cavity
Contains strands of fibrin, phagocytic cell & proteolytic enzymes
Copper IUDs
→ Release a small amount of the metal
→ Producing an even greater inflammatory response
Stimulate the formation of prostaglandin
Smooth muscle contraction & inflammation
→ The altered intrauterine environment
↓ Sperm passage
↓ fertilization
Mechanism of Action
The natural progesterone in the Progestasert
→ endometrial atrophy
The levonorgestrel in the Mirena
Much more potent than natural progesterone
Blood levels of the hormone
Half of the levonorgestrel subdermal implant (Norplant)
→ Block ovulation
The IUD is not an abortifacient
Contraceptive effectiveness
→ not depend on interference with implantation
Effectiveness
The copper T380A and the levonorgestrel T
Remarkably low pregnancy rates
Less than 0.2 per 100 woman-years
Total pregnancies over a 7-year period
The levonorgestrel T : 1.1 per 100 woman
The copper T380A : 1.4 per 100 woman
Benefits
The ParaGard and the Mirena IUDs
Protect against ectopic pregnancy
Progesterone or levonorgestrel → Menstrual bleeding & clamping↓
Risks
Infection
The relative risk for PID
Progestasert : 2.2
Copper 7 : 1.9
Saf-T-Coil : 1.3
Lippes Loop : 1.2
↑Risk was detectable within 4 months of insertion
The rate of diagnosis of PID →1.6 cases per 1,000 women per year
Exposure to sexually transmitted pathogens
More important determinant of PID than the wearing of an IUD
PID with actinomycosis → only in women wearing an IUD
Risks
Pelvic Inflammatory Disease
When PID is suspected in IUP-wearing woman
→ The IUD should be immediately removed
→ High-dose antibiotic therapy should be started
Risks
Ectopic Pregnancy
In 5% of IUD wearers
d/t the fallopian tubes are less well protected against pregnancy
than uterus
Copper T380A or levonorgestrel T
Compared with women using no contraception
→ 80% to 90% reduction in the risk for ectopic pregnancy
Greater reduction than that seen for users of barrier methods
Risks
Fertility
↑Twofold in the risk for infertility associated with tubal factors
The Oxford Study : giving birth just as promptly after IUD removal
Exposure to sexually transmitted pathogens
→ Confers risk for infertility
IUD – Clinical Management
Contraindications to IUD use
Pregnancy
A history of PID
Undiagnosed genital bleeding
Uterine anomalies
Large fibroid tumors
Chronic immune suppression
Copper allergy and Wilson’s disease
Clinical Management
Insertion
The cervix is exposed with a speculum
The uterine cavity should be measured with a uterine sound
A paracervical block
Use of a tenaculum for insertion is mandatory to prevent perforation
With the ParaGard and the Progestasert, the outer sheath of the
inserter is withdrawn a short distance to release the arms of the T
→10mL of 1% lidocaine mixed with atropine (0.5mg)
→ gently pushed inward again to elevate the now-opened T
against the fundus
With the Mirena IUD, insertion is somewhat different
The inserter tube loaded with the IUD is introduced into the uterus
Until the preset sliding flange on the inserter is 1.5 to 2cm from the
external os of the cervix
Clinical Management
Intrauterine Devices in Pregnancy
IUD should be removed as soon as possible
Options for management (if the IUD is present)
Therapeutic abortion
Ultrasound-guided intrauterine removal of the IUD
Continuation of the pregnancy with the device left in place
If the IUD is not in a fundal
To prevent later septic abortion, premature rupture of the membranes & premature birth
→ Ultrasound-guided intrauterine removal of the IUD
If the IUD is in a fundal
→ Continuation of the pregnancy with the device left in place
IUD – Duration of Use
Progestasert
Copper T380A
Approved for 10 years
Levonorgestrel T
Replaced at the end of 1 year
Approved for 5 years
Actinomyces-like particles should be found
Removal of the IUD
Treatment with oral penicillin
IUD – Choice of Devices
Copper T380A & levonorgestrel T
Protection for many years
Low pregnancy rates
↓Risk for ectopic pregnancy
Progestasert
Must be replaced annually
Risk for infection with each insertion
Increasing cost
↑Risk for ectopic pregnancy
↓ The amount of menstrual bleeding & dysmenorrhea
Hormonal Contraception
Hormonal Contraception
Combination OCs
Female sex steroids , Synthetic estrogen
Synthetic progesterone (progestin) , Progestin only
The most widely used hormonal contraception
Administered for 21days beginning on the Sunday after a menstrual
period → discontinued for 7 days to allow for withdrawal bleeding
Progestin-only formulations
Take every day without interruption
Hormonal Contraception
Injectable progestins
Estrogen-progestin combinations
Subdermal implants releasing progestin
Experimental vaginal ring
Release either estrogen-progestin or progestin alone
Silastic ring
Worn in the vagina release steroid hormones
Absorbed at a constant rate
Containing levonorgestrel or combinations of levonorgestrel and
estrogen
Hormonal Contraception - Steroid Hormone Action
Progestins
Progestins are synthetis compounds that mimic the effect of
natural progesterone but differ from it structurally
Three classes
Estranes ┓ 19-nor progestin & used in oral contraceptives in US
Gonanes ┛
Pregnane (or 17-acetoxy compounds)
Similar to progesterone → bound by the progesterone receptor
Medroxyprogesterone acetate (Provera) : major injectable progestin
Some directly bound to the receptor( levonorgestrel, norethindrone)
Require bioactivation ( i.e. desogestrel )
Three newer progestins
Norgestimate , desogestrel, and gestodene → little androgenic effect
Hormonal Contraception - Steroid Hormone Action
Estrogens
In the United States, OCs contain either of two estrogens
Mestranol or ethinyl estradiol
Mestranol requires bioactivation releasing the active agent EE
OCs with 35µg of EE provide the same blood levels of hormone as
do OCs containing 50 µg of mestranol
Antifertility Effects
Combination Oral Contraception
Suppress basal follicle-stimulating hormone (FSH) and LH
↓ Ability of the pituitary gland to synthesize gonadotropines
→
→
→
→
Ovarian follicles do not mature
Little estradiol is produced
There is no midcycle LH surge
Ovulation does not occur
Antifertility Effects
Progestin-only Preparations
Progestin-only “minipill”→ 0.3mg of norethindrone per day (Micronor)
of cycles : ovulatory
: inadequate luteal function
: follicular maturation without ovulation
: complete suppression of follicle
At moderate blood levels of progestin
40%
25%
18%
18%
Normal basal levels of FSH and LH
Some follicle maturation → estradiol trigger LH releasing
However, no answering LH surging & no ovulation
At higher blood levels of progestin
FSH↓ & Follicular activity↓ → Estradiol producton↓ & no LH surge
Antifertility Effects
Hormonal Implants
Release levonorgestrel (Norplant)
In the first year of use, ovulation occurs in about 20% of cycles
The proportion of ovulatory cycles increases with time
Mechanism
Low-dose progestins include effects on the cervical mucus ,
endometrium & tubal motility → sperm migration↓
Nuclear estrogen receptor levels↓& progesterone receptor ↓
→ Activity of the enzyme 17-hydroxysteroid dehydrogenase ↑
that metabolizes natural estradiol 17β
Antiprogesterone mefipristone (RU486)
→ Given before ovulation it can be delayed for several days
Oral contraceptives
Combination OCs
Progestin-only OCs
Pregnancy rates as low as two to three per 1,000 women per year,
when used consistently
Less effective
Three to four per 1,000 women per year
Injectable progestins & implants
Much less subject to user error
Comparable to pregnancy rates after tubal sterilization
Oral contraceptives - Metabolic Effects and safety
Venous Thrombosis
Older studies linked OC use to venous thrombosis & embolism,
cerebral vascular accidents, and heart attack
More recent studies found a much lower risk
Other obvious predisposing causes of thrombosis
→ Contraindications to OC use
Previous thrombosis
Preexisting vascular disease
Coronary artery disease
Leukemia
Cancer
Serious trauma
Oral contraceptives - Metabolic Effects and safety
Venous Thrombosis
Estrogens affect procoagulant & anti-coagulant systems
Fibrinolysis (anticoagulant) is increased as much as coagulant
Balance at increased levels of production & destruction of fibrinogen
The lower estrogen dose reduces the risk for a thromboembolic
event when compared with higher-dose
Smokers taking low-dose OCs
↑ Activation of the coagulation system than nonsmoker
Oral contraceptives - Metabolic Effects and safety
The absolute risk for thrombosis in OC users taking pills
containing 30 to 35㎍ EE is 3 per 10,000 per year
Compared with 1 per 10,000 reproductive-aged women
not using OCs & 6 per 10,000 in pregnancy
Thrombosis risk is apparent by 4 months after starting estrogencontaining OCs
Not increase further with continued use
Risk is highest during the first year of use
Oral contraceptives - Metabolic Effects and safety
Thrombophilia
Hemostatic variables in women given lower-dose OCs who had
previous thrombosis with OCs and compared with no thrombosis
( Bloemenkamp and colleagues)
↑Factor VII,VIII, and protein C
↓Antithrombin III, activated protein C sensitivity ratio, and protein S
Women who had previous thrombosis with OCs → pronounced changes
Factor V Leiden
Genetic variation : 3% to 5% of the white population
Mutation in the factor V protein, inhibiting cleavage of the protein by
activated protein C
Risk for thromboembolic episode : 27.2 per 10,000 woman-years
Oral contraceptives - Metabolic Effects and safety
Thrombophilia
OCs containing newer agents ( i.e., prodestins, desogestrel,or gestodene )
Lewis and colleagues
→ Modest increased risk for venous thrombosis than older progestins
Attrition of susceptibles & adverse selection
Venous thrombosis attributable to OCs during the initial months of use↑
Compared new users to women already taking OCs for some time
without incident → risk ↑
A large European study of thrombosis with different OCs
Apparent risk for thrombosis was lowest with the first low-does pills
introduced & highest with those recently introduced
Oral contraceptives - Metabolic Effects and safety
Ischemic Heart Disease
Ischemis heart and stroke
Principal determinants of risk
Major causes of death blamed on OC use in the past
Advancing age & cigarette smoking
With the higher-does OCs used in the 1980s
Smoking had a profound effect on risk
Smoking 25 or more cigarettes per day had a 30-fold increased risk
for myocardial infarction if they used OCs , compared with nonsmokers
not using OCs
Oral contraceptives - Metabolic Effects and safety
Ischemic Heart Disease
Use of OCs is now much safer
Because most women are taking low-dose pills
Physicians prescribe selectively, excluding women with major
cardiovascular risk factors
Nearly all current users took OCs with less than 50 ㎍ of EE
Current users of low-dose OCs had no increased risk for myocardial
infarction (California study and a study from Washington State)
Adjustment for major risk factors and sociodemographic factors
Age, illness, smoking, ethnicity, and body mass index
After adjustment → risk for myocardial infarction was not increased
Oral contraceptives - Metabolic Effects and safety
Ischemic Heart Disease
One study of so-called third-generation OCs
OCs containing the new progestins desogetrel or gestodene
→ myocardial infarction↓than OCs with similar estrogen dose
Myocardial infarction risk is strongly increased among smokers
→Smokers who used OCs containing the new progestins
→ less likely to have myocardial infarction than the older OCs
Oral contraceptives - Metabolic Effects and safety
Oral contraceptive and Stroke
OC use appeared to be linked to risk for both hemorrhagic &
thrombotic stroke (1970s)
New information shows no risk for women who are healthy
Petitti and colleages study
Hypertension, diabetes, obesity, current smoking, and black race
→ strongly associated with stroke risk
Neither current nor past OC use was associated with stroke
WHO study
European women using low-dose OC
→ no increased risk for either type of stroke, thrombotic or hemorrhagic
European women using high-dose OC → risk↑
Oral contraceptives - Metabolic Effects and safety
Oral contraceptive and Stroke
Smokers and women with hypertension and diabetes
Increased risk for cardiovascular disease whether or not use OCs
WHO study ( if they use low-dose OCs )
Smokers taking OCs → 7 times the risk for ischemic (thrombotic) stroke
Hypertension → 10-fold increased risk (if they took OCs)
The current U.S. practice of limiting OC use by women older than 35
years of age to nonsmokers without other vascular risk factor is prudent
Oral contraceptives - Metabolic Effects and safety
Blood Pressure
Glucose Metabolism
Dose-related effect on blood pressure
Older high-dose pills → 5% higher than 140/90mmHg
Estrogen → renin substrate↑ → BP ↑
Progestins exhibit insulin antagonism → insulin level ↑
The effect is related to androgenic potency of the progestin & dose
Lipid Metabolism
Androgens & estrogens → competing effects on hepatic lipase
Estrogens → LDL↓ & HDL↑ TG ↑
Androgens → LDL ↑ & HDL ↓
Oral contraceptives - Metabolic Effects and safety
Other Metabolic effects
Estrogen in OCs
Circulating-thyroid-bind globulin ↑
Total thyroxine (T4) ↑ & triiodothyronine (T3) resin uptake↓
The results of actual of TFT → normal by free T4 & radioiodine tests
Oral contraceptives and Neoplasia
Endometrial Cancer and Ovarian cancer
Combination OCs reduced the risk for subsequent
endometrial cancer and ovarian cancer
A recent study found that as little as 1 year of OC use was
protective & continued use reduced risk by 7% per year
Benefit persisted for 15 years after last use , with little
diminution
50% reduction in ovarian cancer risk was observed for women
who took OCs for 3 to 4 year
80% reduction was seen with 10 or more years use
Oral contraceptives and Neoplasia
Cervical cancer
A weak association between OC & squamous cancer of the cervix
Risk factors
Early sexual intercourse
Exposure to human papillomavirus
If a woman already has HPV, OC use does not further increase her
risk for cervical neoplasia
Among women who are HPV negative, OC use doubles the risk of
having such a lesion
Adenocarcinoma of the cervix
Rare but not easily detected → incidence↑
Doubling of risk with OCs use
Oral contraceptives and Neoplasia
Breast Cancer
Generally, no increase in overall risk is found from OC use
Some studies → the risk may increase in women OC use
Used OCs For many year
Nulligravid
Young at the time of diagnosis
Continue using OCs in their 40s
Progestin-only OCs → protective effect
OC users who developed breast cancer were more likely to be diagnosed
in early stages & less likely to have LN involvement
Oral contraceptives and Neoplasia
Breast Cancer (Collaborative Group’s study)
Diagnosed while women were taking OCs
Greater risk in women who started OC use before 20 years of age
Less advanced than those in women who had never used OCs
Breast cancer is rare before 20 years of age
No increase in actual numbers
A term pregnancy → short-term increase in breast cancer risk
Growth-enhancing effects of estrogen
The effects of OCs may promote growth of existing cancers
Oral contraceptives and Neoplasia
Liver Tumors
OCs implicated as a cause of benign adenomas of the liver
Newer low-dose product → less risk
No association between OC use & subsequent liver cancer