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=Contraception=
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Introduction  to  Clinical Medicine Women’s Healthcare  Contraception  
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==Objectives==
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*Review basic statistics concerning population growth and pregnancy rates
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*Review basic contraceptive options
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*Review sterilization options
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John Stutsman MD
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==World population growth==
 
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*Population growth is logarithmic since around 1950.
 
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*The world is growing at about 1.8% each year.
 
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*Every minute, a woman dies of pregnancy / childbirth complications.
 
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**99% of these deaths occur in developing countries.
 
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**1 million children left motherless.
 
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*Maternal mortality rates vary from 1/7 (Niger) to 1/17.4k (Sweden).
 
 +
 +
familyplanning
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*Birth control is controversial for three reasons:
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Reality
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**Personal issues
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**Religious issues
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**Political issues
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==Counseling==
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*Counseling about contraception is important.
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*10% of women don't use birth control.
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*53% of unintended pregnancies result from these 10% of women (who aren't using birth control).
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*Abortions are highest in those less than 15yo.
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**Abortions decrease as the woman ages to 30-34.
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**Abortions increase again from 35 and up.
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*In 2002 there were 6.4 million pregnancies.
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Objectives
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**51% were intended
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**49% were unintended
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***22% were unintended ''births''
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***20% were elective abortions
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***7% were fetal losses
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 +
•
 +
Review basic statistics concerning population growth and pregnancy rates
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*Of unintended pregnancies that proceed to live births,
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•
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**1/4 are '''"unwanted"'''
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Review basic contraceptive options
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**3/4 are '''"mistimed"'''
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 +
•
 +
Review sterilization options
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*Of unintended pregnancies that proceed to live births, about 40% of women were using contraceptives at the time of conception.
 
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==Abortion rates==
 
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*The United States of America aborts 22.9 of each 1000 fetuses.
 
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*Australia: 22.2 / 1000
 
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==Birth Controls==
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World Population Growth
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*There are two categories of birth control: contraception (prevent conception) and implant preventors.
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*Contraceptions include:
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**OCPs
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**Norplant
+
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**Depo-Provera
+
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**Condoms
+
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**Diaphragm
+
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**Foam
+
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**Rhythm
+
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**IUDs
+
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*Implant preventors include IUDs and morning after pills.
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 +
33
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*The most commonly used birth control is tubal ligation making up nearly 50% of contraception use in "non-developed" countries.
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United Nations Millennium Goals
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===Barrier methods===
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*Barrier methods include: spermacides, condoms, diaphragms / cervical caps, and sponges
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Quick Facts from the UN
 +
•Every minute, a woman dies of complications related to pregnancy and childbirth or 500K/yr – 99% live and die in developing countries
 +
•Maternal Mortality Rates: in Niger (1 in 7) vs Sweden (1 in 17.4K)
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*Spermacides
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•Every year, more than 1 million children are left motherless because of maternal death.  
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**The active ingredient of spermacides is '''nonoxynol 9''' or '''actoxynol-3'''.
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***Nonoxynol and actoxynol disrupt the spermatic cell membrane.
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**The failure rate of spermacides is '''15-35%'''.
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**Patient compliance is generally high.
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*Condoms
 
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**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.
 
 +
goals1
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*Diaphragms
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Controversial
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**Mechanism of action is to physically block sperm from gaining access to upper reproductive tract (uterus and fallopian tube.
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**Diaphragms can also hold spermicide.
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**Device must be inserted 1 hour before intercourse.
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**Diaphragm must remain in place for 6-8 hours post-coitus.
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**Failure rate is 10-25%
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**Benefits include:
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***'''Some protection agains STDs'''
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***Effective immediately
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***Does not affect breast feeding
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***Does not interfere with intercourse (can be inserted up to 6 hours pre-coitus).
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***No health risks.
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***No systemic side effects.
+
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**Contraindications include:
+
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***Hx of toxic shock syndrome
+
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***Allergy to rubber
+
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***Allergy to spermicides
+
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***Repeat UTIs
+
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***Uterine prolapse
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***Vaginal stenosis
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***Genital anomalies
+
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**Patient compliance is difficult
+
 +
•
 +
Personal
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*The sponge
+
•
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**Mechanism: contains spermicide
+
Religious
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**Benefits: small, disposible, works for 24 hours (regardless of coitus count)
+
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**Reintroduced to market in 2009.
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**Failure rate: 26-40%
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 +
•
 +
Political
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===Hormonal contraceptives===
 
-
*Hormonal contraceptives come as oral pills, as injectables, and as an intravaginal ring or a supradermal patch.
 
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*Injectable contraceptives include:
 
-
**Combined injectible contraceptives (CICs)
 
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**Depo-provera
 
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**Norplant
 
-
**Implanon
 
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====Oral contraceptive pills====
 
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*'''Failure rate is <1%'''
 
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*OCPs can be '''progesterone only''' or '''a combination of estrogen and progesterone''' (combined oral contraceptives; COCs).
 
 +
42
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*Oral contraceptive pills are taken 21 days with 7 days of placebo or no pill.
+
Why Counseling is Important
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*Combined oral contraceptives come in three types depending on their phase:
+
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**Monophasic: all 21 pills, all of which have some amount of estrogen / progesterone (E/P)
+
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**Biphasic: 21 active pills, 2 different combinations of E/P
+
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**Triphasic: 21 active pills, 3 different combinations of E/P
+
 +
•
 +
Abortion Rates, by age group, per 1000 births (2000 Stats)
-
=====OCP mechanism of action=====
+
•
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*Presence of progesterone decreases FSH and LH levels, including the LH surge.
+
10% of women don’t use contraception –
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*Without the LH surge, '''ovulation does not occur'''.
+
These account for 53% of unintended pregnancies
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*Furthermore the '''endometrial lining is ''thinner'' which makes implantation less likely'''.
+
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*The '''cervical lining is ''thickened'' which prevents spermatic penetration''' to the upper reproductive tract.
+
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=====OCP Benefits=====
 
-
*Contraceptive benefits of OCP:
 
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**Highly effective (failure rate <1%)
 
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**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.''
 
 +
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=====OCP Effectiveness=====
+
34
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*Perfect use is what is tested but then there is actual or typical use.
+
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**OCP (combined versions) are 97% effective when taken perfectly.
+
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**OCP (combined versions) are 92% effective upon actual use.
+
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*10 million women are taking OCP; therefore each 1% decrease in effectiveness yields 100k unintended pregnancies
+
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**8% decrease simply from perfect use to typical use.
+
 +
 +
Unintended%20pregnancy
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=====OCP Contraindications=====
+
prams_1
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*Absolute contraindications include:
+
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**History of vascular disease: pulmonary embolism, deep vein thrombosis, coronary vascular atherosclerosis
+
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**Systemic disease: lupus, chronic hypertension, liver disease, hypercholesterolemia, migraine headaches  ''with auras''.
+
 +
prams_2
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*Relative contraindications include:
 
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**Tobacco use
 
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**>35 yo
 
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**Depression
 
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**Seizures '''without auras'''
 
-
====Injectables====
+
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*Mechanism of action:
+
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**Suppress ovulation
+
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**Thicken cervical mucosa
+
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**Thin endometrium
+
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*Types of injectable birth controls include:
+
General Mode of Action
-
**CICs (like OCPs)
+
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**Depo-Provera
+
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**Norplant
+
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**Implantation
+
 +
•
 +
Prevention of Conception –
 +
OCPs, Norplant, Depo-Provera, Condom, Diaphragm, Foam, Rhythm, IUDs
-
*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.
 
 +
•
 +
Prevention of Implantation –
 +
IUDs, “Morning After Pills” 
-
*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
 
-
===Contraceptive Ring===
 
-
*NuvaRing
 
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*2 inches in diameter
 
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*120mg etonogestrel, 15mg ethinyl estradiol
 
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*'''As effective as OCP'''
 
-
*One ring / cycle
 
-
**3 weeks in the vagina, 1 week without
 
-
*'''Not a barrier!'''
 
-
===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.
 
-
==Intra-uterine Devices (IUD)==
 
-
*'''Failure rate of 0.2-3%'''
 
-
*Mechanism of action '''can be contraceptive or abortive'''.
+
18
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**Interferes with sperm ability to travel through uterine cavity.
+
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**Thickens the cervical mucus.
+
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**Intereferes with reproductive process before ova can reach the uterine cavity.
+
-
**Modifies the endometrial lining to decrease implantation.
+
 +
Worldwide Use of Contraceptive Types
-
*IUD advantages:
+
•
-
**Non-hormonal
+
Prevalence of Selected forms of Contraception in Developed and Developing Countries
-
**Failure rate of only 0.2-3%
+
-
**Effective immediately
+
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**Long-term (up to 10 years)
+
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**Does not interfere with intercourse
+
-
**Immediate return to fertility upon removal
+
-
**Does not affect breast feeding
+
 +
•
 +
Projected Use of Contraception in Developing Countries for 2000
-
*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
 
-
==Sterilization==
+
24
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*Sterilization is '''the most common method of birth control among married couples'''.
+
25
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*Sterilization is '''the most common method of birth control globally'''.
+
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*Only 1% regret sterilization.
+
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*'''Failure rate is 1-2% over 10 years'''
+
 +
Barrier Methods
-
*10% of couples choosing sterilization choose vasectomy
+
•
-
**'''Failure rate of vasectomy is 0.1%'''
+
Spermacides
-
==Miscellaneous==
+
•
-
*Laction is a good birth control, too.
+
Condoms
-
**'''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.
+
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**Limitations
+
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***Does not protect against STDs
+
-
***No longer effective once menses begin again
+
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***Hard to maintain because of social aspects of breast feeding
+
 +
•
 +
Diaphragm & Cervical Caps
-
*NFP / Rhythm birth control
+
•
-
**Requires that couples be highly motivated to maintain compliance.
+
Sponges
-
**'''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.
 
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**Failure rate is 20-25%
 
-
==Emergency Contraception==
 
-
*"Morning after" pill
 
-
**Debates over whether it is a contraceptive or an abortifacent
 
-
*IUD
 
-
**Abortifacent
 
-
===Morning After Pill===
+
Spermacides
-
*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'''
+
 +
•
 +
Active Ingredient –
 +
Either Nonoxynol 9 or Actoxynol-3
-
==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
 
 +
•
 +
Failure Rate –
 +
15 to 35%
-
*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
 
 +
•
 +
Patient Compliance –
 +
HIGH
-
=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.
+
Spermacide1
-
*Cost of unintended pregnancy:
+
Condoms
-
**birth, abortions, fetal loss.
+
-
**5 billion dollars.
+
-
==Contraception Counseling==
+
•
-
*Should be part of any exam!
+
Male Condom –
 +
Slippage/Breakage Rate: 5-8%
-
*Process / questions:
+
–
-
**How important is it to you to avoid pregnancy now?
+
Failure Rate: 5-15%
-
**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.
+
Female Condom –
-
**Cheapest -> expensive
+
Slippage/Breakage Rate: 3%
-
***Copper IUD ($540)
+
-
***Vasectomy
+
-
***Injectable
+
-
***OCP ($1784)
+
-
***Condom ($2424)
+
-
***Ligation
+
-
***Withdrawal
+
-
***Periodic abstinence ($3450)
+
-
***Female condom
+
-
***Sponge
+
-
***Cervical cap ($5730)
+
-
***None ($14663)
+
-
==Types==
+
–
 +
Failure Rate: 5-15%
-
===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!
 
 +
40
 +
43
 +
FCondom
 +
FCondom2
 +
Copy of FCondom7
 +
39
-
*Diaphragm
+
Diaphragms
-
**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
+
-
===Hormonal methods===
+
•
-
*The pill
+
Mechanism of Action
-
**OCP = oral contraceptive pills
+
-
**Pill, patch, ring
+
 +
•
 +
Failure Rate: 10-20%
-
*Injection
+
•
-
**Every 3 months
+
Benefits
-
**Slightly more effective
+
-
**Weight gain common, irregular bleeding
+
-
***Results in cessation
+
-
**Cessation results in decreased effectiveness.
+
-
**Can be used to treat heavy bleeding too.
+
 +
•
 +
Precautions
-
*Implant
+
•
-
**Norplant had silicon and lawsuits caused it to be taken off the market.
+
Patient Compliance: –
-
**Implanon = Nexplanon
+
Inserted 1 hr before
-
***A source of estrogen (etonogestrel)
+
-
====Mechanism of Hormonal contraceptions====
+
–
-
*Ovulation is presented by providing feedback with progesterone to decrease LH surge.
+
Left in place for 6-8 hrs post-coitus
-
*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
 
-
===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.
 
 +
37
 +
Diaphragm1
-
*Very low failure rate: 0.2-0.8%
+
Diaphragms
 +
 +
Diaphragm6
 +
Diaphragm6
 +
Diaphragm3
-
*Contraindications:
+
The Sponge
-
**Recent PID
+
-
**Suspicion of genital cancer
+
-
**Pelvic TB
+
 +
•
 +
Small, disposable; contains spermacide
-
===Emergency Contraception Options===
+
•
-
*EE and progestin
+
Once in place, can provide contraception for 24hrs no mater how often coitus occurs
-
**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.
+
 +
•
 +
Today Sponge off US market in 1995 but reintroduced in May ‘09
-
*Indications:
+
•
-
**Intercourse within past 72-120 hours without contraceptive protection (independent of time in the menstrual cycle)
+
Other Brands available worldwide
-
**Contraceptive mishap
+
-
**Barrier method dislodgment/breakage
+
-
**Expulsion of IUD
+
-
**Missed oral contraceptive pills
+
-
**Sexual assault
+
-
**Exposure to teratogens (eg, cytotoxic drug)
+
-
***Retinae
+
 +
•
 +
Failure Rate: 26-40%
-
*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:
+
elaine01-black_dress
-
**No better and maybe less effective than just using progestin alone.
+
-
**High side effects (n/v)
+
-
**Requries prescription.
+
 +
Hormonal Contraceptives
 +
•
 +
OCPs
-
===Permanent Birth Control===
+
•
-
*Vasectomy
+
Injectable –
-
**Office procedure
+
Combined Injectable Contraceptives (CICs)
-
**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.
+
-
==Elective Abortions==
+
–
-
*'''Decrease in number and rate.'''
+
Depo-Provera
-
*Decrease in abortion-related deaths.
+
-
*Maternal mortality is actually increasing though (independent of abortions).
+
-
*950% are done in the first trimester
+
 +
–
 +
Norplant
-
*Two major methods:
+
–
-
**Surgical: D&C
+
Implanon
-
**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
+
-
==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)
 
 +
•
 +
New Types –
 +
Ring
-
*Contraindication to IUD:
+
–
-
**?
+
Patch 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
OCPs
 +
 
 +
•
 +
Types –
 +
Combination of estrogen & progesterone
 +
 
 +
–
 +
Progesterone Only
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
OCP1
 +
 
 +
OCPs
 +
 
 +
•
 +
Mechanism of Action –
 +
Decrease FSH & LH
 +
 
 +
–
 +
No LH surge
 +
 
 +
–
 +
Alter Cervical Mucus
 +
 
 +
–
 +
Alter Endometrial Lining
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
11
 +
OCP2
 +
 
 +
OCPs
 +
 
 +
•
 +
Benefits –
 +
Contraceptive •
 +
Failure Rate: 1% or less
 +
 
 +
 
 +
 
 +
 
 +
–
 +
Non-Contraceptive
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
OCP3
 +
 
 +
OCPs
 +
 
 +
 +
 +
OCP4
 +
 
 +
OCP Effectiveness
 +
 
 +
•
 +
Efficacy –
 +
Perfect use vs. actual or typical use
 +
 
 +
–
 +
Combined OCP •
 +
99.7% perfect use vs 92% actual use
 +
 
 +
•
 +
Currently, there are 10 million women using the pill –
 +
Each 1% decrease in efficacy = 100K unintended pregnancies each year 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Or, about 3 Jumbo jets crashing each and every day
 +
 
 +
 
 +
 
 +
 
 +
OCPs
 +
 
 +
•
 +
Contraindications –
 +
Absolute •
 +
Hx/o Vascular Dz –
 +
PE, DVT, CVA
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Systemic Dz –
 +
SLE, cHTN, Active Liver Dz, HyperChol, MiHAs with Auras
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 +
–Relative •Tob Use, >35yrs, Depression, MiHAs without Auras
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
09
 +
10
 +
 
 +
Injectables
 +
 
 +
•
 +
Mechanism of Action –
 +
Suppress ovulation, thicken cervical mucus, alter endometrium
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Types –
 +
CICs
 +
 
 +
–
 +
Depo-Provera
 +
 
 +
–
 +
Norplant
 +
 
 +
–
 +
Implanon
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Failure Rates –
 +
CICs: 0.1 – 1%
 +
 
 +
–
 +
Depo-Provera 0.1 - 0.6%
 +
 
 +
–
 +
Norplant/Implanon: •
 +
0.2 - 0.6%
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
PICs1
 +
 
 +
Injectables
 +
 
 +
 +
CIC5
 +
CIC5
 +
 
 +
Newest Additions
 +
 
 +
•
 +
Contraceptive Ring
 +
 
 +
•
 +
Contraceptive Patch
 +
 
 +
 
 +
 
 +
 
 +
Contraceptive Ring
 +
 
 +
•
 +
NuvaRing –
 +
2 inch diameter
 +
 
 +
–
 +
120mg etonogestrel & 15mg ethinyl estradiol
 +
 
 +
–
 +
As effective as OCPs
 +
 
 +
–
 +
One Ring/Cycle •
 +
3 wks in/1 wk out
 +
 
 +
•
 +
Not a Barrier
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
nuvaring
 +
nuvaring
 +
 
 +
Contraceptive Patch
 +
 
 +
•
 +
Ortho Evra –
 +
20-cm patch
 +
 
 +
–
 +
150mg Norelgestromin & 20mg ethinyl estradiol
 +
 
 +
–
 +
“Superior” compliance rate vs/ OCP users (90% vs/ 77%)
 +
 
 +
–
 +
As effective as OCPs
 +
 
 +
–
 +
Three Rings/Cycle •
 +
1 patch/wk x3wks
 +
 
 +
•
 +
1 wk off
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
Patch2
 +
 
 +
IUDs
 +
 
 +
•
 +
Types –
 +
Three Types in US
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Mechanism of Action –
 +
Contraceptive vs/ Abortative
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Advantages –
 +
Non-Hormonal
 +
 
 +
–
 +
Failure Rate: 0.2% to 3% by type
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Disadvantages
 +
 
 +
•
 +
Contraindications 
 +
 
 +
 
 +
 
 +
Mirena1
 +
21
 +
08
 +
IUD1
 +
IUD2
 +
IUD3
 +
 
 +
IUD  
 +
 
 +
 +
 +
IUD6
 +
IUD4
 +
 
 +
Sterilization
 +
 
 +
•
 +
Most Common Method Among Married Couples
 +
 
 +
•
 +
Approximately 1% Regret Rate
 +
 
 +
•
 +
Failure Rate:
 +
 
 +
•
 +
1-2/100 over 10 yrs
 +
 
 +
•
 +
Vasectomy –
 +
Chosen by 10% of couples
 +
 
 +
–
 +
Failure Rate: 0.1%
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
05
 +
07
 +
 
 +
Sterilization
 +
 
 +
 +
Steilization2
 +
Steilization2
 +
 
 +
Miscellaneous
 +
 
 +
•
 +
Lactation –
 +
Failure Rate:1-2/100 for 1st 6 months
 +
 
 +
 
 +
 
 +
 
 +
•
 +
NFP/Rhythm –
 +
Requires highly motivated couples
 +
 
 +
–
 +
Failure Rate: 1-45%
 +
 
 +
 
 +
 
 +
 
 +
•
 +
Withdrawal –
 +
One of the oldest methods
 +
 
 +
–
 +
Failure Rate: 20-25% 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
NFP1
 +
 
 +
NFP
 +
 
 +
 +
basal_temp_graph1
 +
Lactation1
 +
Lactation2
 +
 
 +
Emergency Contraception
 +
 
 +
•
 +
“Morning After” –
 +
Contraceptive or Abortifacent
 +
 
 +
 
 +
 
 +
 
 +
•
 +
IUD –
 +
Abortifacent
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
“Morning After Pill”
 +
 
 +
•
 +
Yuzpe Method or Preven –
 +
2 tablets of 0.25mg levonogestrol/ 0.05mg ethinyl estradiol at 0 hrs and 12hrs
 +
 
 +
 
 +
 
 +
 
 +
•
 +
“Plan B” –
 +
1 tablet of 0.75 mg  Levonorgestrel taken at 0 and 12hr
 +
 
 +
–
 +
Just as effective as Juzpe with less Nausea & Vomitting
 +
 
 +
–
 +
Decreases pregnancy rate from 8% to <1%
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
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
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
Male Alternatives
 +
 
 +
•
 +
Modern Methods –
 +
Vas Occlusion •
 +
“reversible” vasectomy
 +
 
 +
•
 +
Problem: lower efficacy
 +
 
 +
 
 +
 
 +
 
 +
–
 +
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.
 +
 
 +
Mi ik
 +
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
Male Alternatives
 +
 
 +
•
 +
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
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
 
 +
Male Alternatives
 +
 
 +
•
 +
Ancient Romans
 +
 
 +
•
 +
South Pacific
 +
 
 +
 
 +
 +
 
 +
02
 +
03
 +
01
 +
 
 +
 +
 
 +
 
 +
Conclusions
 +
 
 +
 +
35

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