From Iusmicm

Contents 1 Contraception 1.1 Objectives 1.2 World population growth 1.3 Counseling 1.4 Abortion rates 1.5 Birth Controls 1.5.1 Barrier methods 1.5.2 Hormonal contraceptives 1.5.2.1 Oral contraceptive pills 1.5.2.1.1 OCP mechanism of action 1.5.2.1.2 OCP Benefits 1.5.2.1.3 OCP Effectiveness 1.5.2.1.4 OCP Contraindications 1.5.2.2 Injectables 1.5.3 Contraceptive Ring 1.5.4 Contraceptive patch 1.6 Intra-uterine Devices (IUD) 1.7 Sterilization 1.8 Miscellaneous 1.9 Emergency Contraception 1.9.1 Morning After Pill 1.10 Male alternatives 2 Family Planning 2.1 Contraception Counseling 2.2 Types 2.2.1 Barrier methods 2.2.2 Hormonal methods 2.2.2.1 Mechanism of Hormonal contraceptions 2.2.3 IUD 2.2.4 Emergency Contraception Options 2.2.5 Permanent Birth Control 2.3 Elective Abortions 2.4 Questions

[edit] Contraception

[edit] Objectives

• Review basic statistics concerning population growth and pregnancy rates
• Review basic contraceptive options
• Review sterilization options

[edit] World population growth

• Population growth is logarithmic since around 1950.
• The world is growing at about 1.8% each year.
• Every minute, a woman dies of pregnancy / childbirth complications.
  • 99% of these deaths occur in developing countries.
  • 1 million children left motherless.
• Maternal mortality rates vary from 1/7 (Niger) to 1/17.4k (Sweden).

• Birth control is controversial for three reasons:
  • Personal issues
  • Religious issues
  • Political issues

[edit] Counseling

• Counseling about contraception is important.
• 10% of women don't use birth control.
• 53% of unintended pregnancies result from these 10% of women (who aren't using birth control).
• Abortions are highest in those less than 15yo.
  • Abortions decrease as the woman ages to 30-34.
  • Abortions increase again from 35 and up.

• In 2002 there were 6.4 million pregnancies.
  • 51% were intended
  • 49% were unintended
    • 22% were unintended births
    • 20% were elective abortions
    • 7% were fetal losses

• Of unintended pregnancies that proceed to live births,
  • 1/4 are "unwanted"
  • 3/4 are "mistimed"

• Of unintended pregnancies that proceed to live births, about 40% of women were using contraceptives at the time of conception.

[edit] Abortion rates

• The United States of America aborts 22.9 of each 1000 fetuses.
• Australia: 22.2 / 1000

[edit] Birth Controls

• There are two categories of birth control: contraception (prevent conception) and implant preventors.
• Contraceptions include:
  • OCPs
  • Norplant
  • Depo-Provera
  • Condoms
  • Diaphragm
  • Foam
  • Rhythm
  • IUDs
• Implant preventors include IUDs and morning after pills.

• The most commonly used birth control is tubal ligation making up nearly 50% of contraception use in "non-developed" countries.

[edit] Barrier methods

• Barrier methods include: spermacides, condoms, diaphragms / cervical caps, and sponges

• Spermacides
  • The active ingredient of spermacides is nonoxynol 9 or actoxynol-3.
    • Nonoxynol and actoxynol disrupt the spermatic cell membrane.
  • The failure rate of spermacides is 15-35%.
  • Patient compliance is generally high.

• Condoms
  • Male condom failure rate is 5-8% (slippage / breakage) or 5-15%
  • Female condom failure rate is 3% (slippage / breakage) or 5-15%
  • Mechanism of action is to physically block sperm.

• Diaphragms
  • Mechanism of action is to physically block sperm from gaining access to upper reproductive tract (uterus and fallopian tube.
  • Diaphragms can also hold spermicide.
  • Device must be inserted 1 hour before intercourse.
  • Diaphragm must remain in place for 6-8 hours post-coitus.
  • Failure rate is 10-25%
  • Benefits include:
    • Some protection agains STDs
    • Effective immediately
    • Does not affect breast feeding
    • Does not interfere with intercourse (can be inserted up to 6 hours pre-coitus).
    • No health risks.
    • No systemic side effects.
  • Contraindications include:
    • Hx of toxic shock syndrome
    • Allergy to rubber
    • Allergy to spermicides
    • Repeat UTIs
    • Uterine prolapse
    • Vaginal stenosis
    • Genital anomalies
  • Patient compliance is difficult

• The sponge
  • Mechanism: contains spermicide
  • Benefits: small, disposible, works for 24 hours (regardless of coitus count)
  • Reintroduced to market in 2009.
  • Failure rate: 26-40%

[edit] Hormonal contraceptives

• Hormonal contraceptives come as oral pills, as injectables, and as an intravaginal ring or a supradermal patch.
• Injectable contraceptives include:

**Combined injectible contraceptives (CICs)

• • Depo-provera
  • Norplant
  • Implanon

[edit] Oral contraceptive pills

• Failure rate is <1%
• OCPs can be progesterone only or a combination of estrogen and progesterone (combined oral contraceptives; COCs).

• Oral contraceptive pills are taken 21 days with 7 days of placebo or no pill.
• Combined oral contraceptives come in three types depending on their phase:
  • Monophasic: all 21 pills, all of which have some amount of estrogen / progesterone (E/P)
  • Biphasic: 21 active pills, 2 different combinations of E/P
  • Triphasic: 21 active pills, 3 different combinations of E/P

[edit] OCP mechanism of action

• Presence of progesterone decreases FSH and LH levels, including the LH surge.
• Without the LH surge, ovulation does not occur.
• Furthermore the endometrial lining is thinner which makes implantation less likely.
• The cervical lining is thickened which prevents spermatic penetration to the upper reproductive tract.

[edit] OCP Benefits

• Contraceptive benefits of OCP:
  • Highly effective (failure rate <1%)
  • Effective immediately if started by day 7 of menstrual cycle.
  • Pelvic examination not required to initiate use.
  • OCPs do not interfere with intercourse.
  • Few side effects.
  • Convenient and easy.
  • Client can stop use at any time.
  • Can be provided by trained medical staff.

• Non-contraceptive benefits of OCP:
  • Decrease menstrual flow.
  • Decrease menstrual cramps.
  • Improve anemia (?).
  • Protect against ovarian and endometrial cancer.
  • Decrease bening breast disease and ovarian cysts.
  • Prevent ectopic pregnancy.
  • Protect against some causes of pelvic inflammatory disease.

[edit] OCP Effectiveness

• Perfect use is what is tested but then there is actual or typical use.
  • OCP (combined versions) are 97% effective when taken perfectly.
  • OCP (combined versions) are 92% effective upon actual use.
• 10 million women are taking OCP; therefore each 1% decrease in effectiveness yields 100k unintended pregnancies
  • 8% decrease simply from perfect use to typical use.

[edit] OCP Contraindications

• Absolute contraindications include:
  • History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis
  • Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches with auras.

• Relative contraindications include:
  • Tobacco use
  • >35 yo
  • Depression
  • Seizures without auras

[edit] Injectables

• Mechanism of action:
  • Suppress ovulation
  • Thicken cervical mucosa
  • Thin endometrium

• Types of injectable birth controls include:
  • CICs (like OCPs)
  • Depo-Provera
  • Norplant
  • Implantation

• Failure rate for injectables:
  • CICs: 0.1-1%
  • Depo-Provera: 0.1-0.6%
  • Norplant / Implanton: 0.2-0.6%

• Injectable limitations
  • Side effects include: nausea, dizziness, breast tenderness, headaches, spotting, light bleeding
  • Effectiveness lowered in combination with other drugs
  • Can delay return to fertility
  • Serious side effects are possible
  • Do not protect against STDs
  • Change the menstrual bleeding pattern
  • User-dependent; that is, the client must return every 30 days.

• Injectable benefits:
  • Highly effective
  • Effective immediately
  • Pelvic examination not required before use (as with OCPs)
  • Do not interfere with intercourse
  • "Few side effects" (though more than OCPs)
  • Can be provided by trained medical staff
  • No supplies needed by the client

[edit] Contraceptive Ring

• NuvaRing
• 2 inches in diameter
• 120mg etonogestrel, 15mg ethinyl estradiol
• As effective as OCP
• One ring / cycle
  • 3 weeks in the vagina, 1 week without
• Not a barrier!

[edit] Contraceptive patch

• Ortho Evra
• 150 mg norelgestromin, 20mg ethinyl estradiol
• As effective as OCPs
• Better compliance (90%) than OCPs (77%)
• Three patches / cycle, one each week for three weeks; 1 week without patch.

[edit] Intra-uterine Devices (IUD)

• Failure rate of 0.2-3%

• Mechanism of action can be contraceptive or abortive.
  • Interferes with sperm ability to travel through uterine cavity.
  • Thickens the cervical mucus.
  • Intereferes with reproductive process before ova can reach the uterine cavity.
  • Modifies the endometrial lining to decrease implantation.

• IUD advantages:
  • Non-hormonal
  • Failure rate of only 0.2-3%
  • Effective immediately
  • Long-term (up to 10 years)
  • Does not interfere with intercourse
  • Immediate return to fertility upon removal
  • Does not affect breast feeding

• IUD contraindications
  • Pregnancy (risk of ectopic pregnancy)
  • Unexplained vaginal bleeding
  • PID
  • Purulent discharge
  • Distorted uterine cavity
  • Malignment trophoblast disease
  • Pelvic TB
  • Genital tract cancer
  • GU tract infection

[edit] Sterilization

• Sterilization is the most common method of birth control among married couples.
• Sterilization is the most common method of birth control globally.
• Only 1% regret sterilization.
• Failure rate is 1-2% over 10 years

• 10% of couples choosing sterilization choose vasectomy
  • Failure rate of vasectomy is 0.1%

[edit] Miscellaneous

• Laction is a good birth control, too.
  • Lactation failure rate is 2% for the first 6th months.
  • Mechanism of action is disruption of GnRH release because of frequent, intense suckling at the nipple.
  • Disrupted GnRH means disrupted LH / FSH release which means no ovulation.
  • Limitations
    • Does not protect against STDs
    • No longer effective once menses begin again
    • Hard to maintain because of social aspects of breast feeding

• NFP / Rhythm birth control
  • Requires that couples be highly motivated to maintain compliance.
  • Failure rate is 1-45%.
  • NFP can be monitored by several methods: calendar, basal body temperature (BBT), cervical mucus method (Billings), or symptothermal (BBT + Billings)

• Withdrawal method birth control
  • One of the oldest methods.
  • Failure rate is 20-25%

[edit] Emergency Contraception

• "Morning after" pill
  • Debates over whether it is a contraceptive or an abortifacent
• IUD
  • Abortifacent

[edit] Morning After Pill

• There are two medicinal methods for emergency birth control:
  • The Yuzpe method is 2 tablets of 0.25 mg loveonogestrol at 0 and 12 hours.
  • The Plan B method is 1 tablet of 0.75 mg levonorgestrel at 0 and 12 hours.
    • Plan B has less n / v
    • Plan B is more effective

[edit] Male alternatives

• Traditional methods
  • Periodic Abstinence
    • High contraceptive efficacy if rules followed perfectly
    • Typical 1st year failure rate: 20%
    • Limited Acceptability: low reliability, inflexibility
  • Non-Vaginal Ejaculation
    • Historically the major pre-industrial method of family planning
    • Limited Reliability: requires skill and self-control
    • Typical 1st year failure rate: 20%
  • Vasectomy
    • Relative Contraindications: bleeding disorders, allergy to anesthestics, scrotal pathology
    • Excises a segment of vas deferens
    • Failure Rate: 0.1% - wait as long as three months
• Condom

• Modern methods
  • Vas Occlusion
    • "reversible vasectomy"
    • Lower efficacy than true vasectomy
  • Heating
    • Principle: brief elevations of testicular temperature suppresses spermatogenesis
    • Concept: tight scrotal support – remains to be clinically proven
  • Immunocontraception
    • Sperm Vaccination – men and women
  • Chemical (non-hormonal)
    • Target the rapidly proliferating germinal epithelium with drugs, heat, ionising radiation, thereby disrupting mitosis and/or meiosis

• Hormonal
  • WHO Studies utilized weekly testosterone enanthate injections
    • Provides both gonadotropin suppression and androgen replacement
    • Contraceptive Failure Rate of about 8%
    • Adverse Affects: cardiovascular & prostatic diseases, mood changes
  • Other Studies looked at Androgen Combination regimens:
    • Non-androgens (estrogen, progestins) to suppress gonadotropins with testosterone
    • GnRH Blockades with testosterone add-back
    • FSH Blockades

[edit] Family Planning

• Historically:
  • Pubarche occured in the upper teens
  • Breastfed 3-4 yrs caused amennorhea which is an excellent, natural birth control
  • Only 50% reached the teens (reproductive age)
    • Disease
    • Starvation

• Now:
  • 7 Billion and counting

• Adolescent Pregnancy:
  • Pregnancy rate is decreasing
  • Birth rate is decreasing
  • Abortion rate is decreasing
  • Adolescent pregnancy in general is decreasing.
  • Trends are across white, Hispanic, and African American races
  • US still has very high teen pregnancy rate compared to other countries

• Incidence of unintended pregnancy is similar with and without contraception but the risk is much higher for those without.

• Cost of unintended pregnancy:
  • birth, abortions, fetal loss.
  • 5 billion dollars.

[edit] Contraception Counseling

• Should be part of any exam!

• Process / questions:
  • How important is it to you to avoid pregnancy now?
  • What would you do if you became pregnant now?
  • What is your desired family size?
  • What is your intended timing for pregnancy?
  • Are there health issues that you need to address before you become pregnant?

• Lactation is effective for 6 months.
  • Must be exclusively breast feeding.

• 5-year cost of contraceptive methods
  • Includes cost of unintended pregnancy.
  • Cheapest -> expensive
    • Copper IUD ($540)
    • Vasectomy
    • Injectable
    • OCP ($1784)
    • Condom ($2424)
    • Ligation
    • Withdrawal
    • Periodic abstinence ($3450)
    • Female condom
    • Sponge
    • Cervical cap ($5730)
    • None ($14663)

[edit] Types

[edit] Barrier methods

• Keeps spermatozoa from meeting egg

• Chemical (foams, spermicides)
  • Can come in sponges, films, or creams

• Physical (condoms)
  • Oldest were sheep skin
  • Female is expensive
  • Getting better at having adolescent males use them.
  • They protect from STDs!

• Diaphragm
  • Made by one company
  • Requires office visit for fitting
  • Catches sperm
  • Fits behind pubic symphisis and behind the cervix
  • Pressure on ureter increases risk for UTI.
  • Can use diaphragm to to catch blood of menses, too.
    • As long as no hx of toxic shock syndrome

[edit] Hormonal methods

• The pill
  • OCP = oral contraceptive pills
  • Pill, patch, ring

• Injection
  • Every 3 months
  • Slightly more effective
  • Weight gain common, irregular bleeding
    • Results in cessation
  • Cessation results in decreased effectiveness.
  • Can be used to treat heavy bleeding too.

• Implant
  • Norplant had silicon and lawsuits caused it to be taken off the market.
  • Implanon = Nexplanon
    • A source of estrogen (etonogestrel)

[edit] Mechanism of Hormonal contraceptions

• Ovulation is presented by providing feedback with progesterone to decrease LH surge.
• Progesterone:
  • Inhibits LH surge such that ovulation is decreased.
  • Makes cervical mucus thick to inhibit sperm motility
  • Smooth muscle relaxant to decrease transport of sperm in the fallopian tube (which has SM and cilia helping to move the sperm toward the egg)
  • Decreases glycogen stores in the endometrium such that ovum is less likely to survive / implant
• Estrogen:
  • decreases FSH such that there is little follicle development
  • increases progesterone receptors so as to potentiate the effect of the progesterone

• Bonus benefits
  • Decreased ectopic preg
  • Regulates menses
    • Good tx for irregular menses
  • Decrease PID / salpingitis risk
    • Good tx with gonorrhea and chlamydia
  • Less acne / hirsuitism
    • Because estrogen increases sex hormone binding globulin (SHBG) at the liver
    • Binds testosterone and decreases androgenic effect
  • Decreased androgen production, too
    • Because test is made in ovary and FSH is decreased
  • Decreased benign breast disease
    • Recall however that benign breast fibrosis has no increased risk for cancer
  • Decreased risk of endometiral cancer
    • 50% risk
    • Last for 15 years!
  • Decreased risk of ovarian cancer
    • 30%
    • 30 years of protection

[edit] IUD

• Very good compliance
• Good for long term use
• Two types in US
  • LNG IUS
  • Copper T (380 A)

• Mechanism of action
  • Impairs sperm motility through uterus via copper.
  • Impairs sperm motility via prosterone's increased thickness effect.
  • Inflammatory environment reaction in the uterus makes hostile to sperm.

• Very low failure rate: 0.2-0.8%

• Contraindications:
  • Recent PID
  • Suspicion of genital cancer
  • Pelvic TB

[edit] Emergency Contraception Options

• EE and progestin
  • Up to 72 hrs postcoital (3 days)
• Levonorgestrel
  • Up to 72 hrs postcoital (3 days)
  • Includes Plan B; purchased over the counter
• Ulipristal acetate (Ella)
  • Up to 120 hrs postcoital (5 days)
  • Requires Rx
• IUD
  • Up to 120 hrs postcoital (5 days)
  • Requires visit to MD.

• Indications:
  • Intercourse within past 72-120 hours without contraceptive protection (independent of time in the menstrual cycle)
  • Contraceptive mishap
  • Barrier method dislodgment/breakage
  • Expulsion of IUD
  • Missed oral contraceptive pills
  • Sexual assault
  • Exposure to teratogens (eg, cytotoxic drug)
    • Retinae

• Hormonal emergency contraception:
  • Not new concept
  • 1920’s: Veterinarians used high doses of estrogen for dogs and horses
  • 1960’s: DES and other estrogens prescribed for human postcoital use
  • 1972  : “Yuzpe method”
    • 100 mcg ethinyl estradiol (high dose birth control pill)
    • 0.5 mg levonorgestrel

• Yuzpe method:
  • No better and maybe less effective than just using progestin alone.
  • High side effects (n/v)
  • Requries prescription.

[edit] Permanent Birth Control

• Vasectomy
  • Office procedure
  • Ligation
• Tubal ligation
  • In-hospital
  • Laproscopic or post-deliver with umbilical incision
• Hysteroscopic Tubal Sterilization
  • Radiofrequency or silicon plug
  • Can be done in the office
  • Decreasing the cost of tubal ligation.
  • Requires follow-up via radiology.

[edit] Elective Abortions

• Decrease in number and rate.
• Decrease in abortion-related deaths.
• Maternal mortality is actually increasing though (independent of abortions).
• 950% are done in the first trimester

• Two major methods:
  • Surgical: D&C
  • Medication
    • 15% of abortions
    • RU486 = Mithacristone (600mg)
    • Can use lower doses but give more vaginally (for fewer side effects)
    • Methotrexate can also be used, but worse

[edit] Questions

• Slowest return to fertility:
  • Depot medroxyprogesterone acetate

• Contraindications to CHC (combined hormone contraceptive):
  • DVT!
  • Not the smoker (until over 35yo), not the rheumatoid arthritic, not the well-controlled HTN (OK while controlled)

• Contraindication to IUD:
  • ?