OBGYN - Family Planning

From Iusmicm

(Difference between revisions)
(Created page with 'Introduction to Clinical Medicine Women’s Healthcare Contraception John Stutsman MD familyplanning Reality Objectives • Review basic statistics conce…')
 
(3 intermediate revisions not shown)
Line 1: Line 1:
-
Introduction  to  Clinical Medicine Women’s Healthcare  Contraception  
+
=Contraception=
-
+
==Objectives==
-
+
*Review basic statistics concerning population growth and pregnancy rates
-
+
*Review basic contraceptive options
-
John Stutsman MD
+
*Review sterilization options
 +
==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).
-
 
-
familyplanning
 
-
Reality
+
*Birth control is controversial for three reasons:
 +
**Personal issues
 +
**Religious issues
 +
**Political issues
-
+
==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.
-
Objectives
+
*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
-
•
 
-
Review basic statistics concerning population growth and pregnancy rates
 
-
•
+
*Of unintended pregnancies that proceed to live births,
-
Review basic contraceptive options
+
**1/4 are '''"unwanted"'''
 +
**3/4 are '''"mistimed"'''
-
•
 
-
Review sterilization options
 
 +
*Of unintended pregnancies that proceed to live births, about 40% of women were using contraceptives at the time of conception.
 +
==Abortion rates==
 +
*The United States of America aborts 22.9 of each 1000 fetuses.
 +
*Australia: 22.2 / 1000
-
World Population Growth
+
==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.
-
33
 
-
United Nations Millennium Goals
+
*The most commonly used birth control is tubal ligation making up nearly 50% of contraception use in "non-developed" countries.
-
+
===Barrier methods===
-
Quick Facts from the UN
+
*Barrier methods include: spermacides, condoms, diaphragms / cervical caps, and sponges
-
•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)
 
-
•Every year, more than 1 million children are left motherless because of maternal death.  
+
*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.
-
goals1
 
-
Controversial
+
*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
-
•
 
-
Personal
 
-
•
+
*The sponge
-
Religious
+
**Mechanism: contains spermicide
 +
**Benefits: small, disposible, works for 24 hours (regardless of coitus count)
 +
**Reintroduced to market in 2009.
 +
**Failure rate: 26-40%
-
•
 
-
Political
 
 +
===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
 +
====Oral contraceptive pills====
 +
*'''Failure rate is <1%'''
 +
*OCPs can be '''progesterone only''' or '''a combination of estrogen and progesterone''' (combined oral contraceptives; COCs).
-
42
 
-
Why Counseling is Important
+
*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
-
•
 
-
Abortion Rates, by age group, per 1000 births (2000 Stats)
 
-
•
+
=====OCP mechanism of action=====
-
10% of women don’t use contraception –
+
*Presence of progesterone decreases FSH and LH levels, including the LH surge.
-
These account for 53% of unintended pregnancies
+
*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.
 +
=====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.''
-
 
-
34
+
=====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.
-
 
-
Unintended%20pregnancy
 
-
prams_1
+
=====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''.
-
prams_2
 
 +
*Relative contraindications include:
 +
**Tobacco use
 +
**>35 yo
 +
**Depression
 +
**Seizures '''without auras'''
-
+
====Injectables====
 +
*Mechanism of action:
 +
**Suppress ovulation
 +
**Thicken cervical mucosa
 +
**Thin endometrium
-
General Mode of Action
+
*Types of injectable birth controls include:
 +
**CICs (like OCPs)
 +
**Depo-Provera
 +
**Norplant
 +
**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
 +
*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!'''
 +
===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%'''
-
18
+
*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.
-
Worldwide Use of Contraceptive Types
 
-
•
+
*IUD advantages:
-
Prevalence of Selected forms of Contraception in Developed and Developing Countries
+
**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
-
•
 
-
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
-
24
+
==Sterilization==
-
25
+
*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'''
-
Barrier Methods
 
-
•
+
*10% of couples choosing sterilization choose vasectomy
-
Spermacides
+
**'''Failure rate of vasectomy is 0.1%'''
-
•
+
==Miscellaneous==
-
Condoms
+
*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
-
•
 
-
Diaphragm & Cervical Caps
 
-
•
+
*NFP / Rhythm birth control
-
Sponges
+
**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%
 +
==Emergency Contraception==
 +
*"Morning after" pill
 +
**Debates over whether it is a contraceptive or an abortifacent
 +
*IUD
 +
**Abortifacent
-
Spermacides
+
===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'''
-
•
 
-
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
-
Spermacide1
+
*''Incidence'' of unintended pregnancy is similar with and without contraception but the ''risk'' is much higher for those without.
-
Condoms
+
*Cost of unintended pregnancy:
 +
**birth, abortions, fetal loss.
 +
**5 billion dollars.
-
•
+
==Contraception Counseling==
-
Male Condom –
+
*Should be part of any exam!
-
Slippage/Breakage Rate: 5-8%
+
-
–
+
*Process / questions:
-
Failure Rate: 5-15%
+
**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
-
Female Condom –
+
**Includes cost of unintended pregnancy.
-
Slippage/Breakage Rate: 3%
+
**Cheapest -> expensive
 +
***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
 
-
Diaphragms
+
*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
-
•
+
===Hormonal methods===
-
Mechanism of Action
+
*The pill
 +
**OCP = oral contraceptive pills
 +
**Pill, patch, ring
-
•
 
-
Failure Rate: 10-20%
 
-
•
+
*Injection
-
Benefits
+
**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.
-
•
 
-
Precautions
 
-
•
+
*Implant
-
Patient Compliance: –
+
**Norplant had silicon and lawsuits caused it to be taken off the market.
-
Inserted 1 hr before
+
**Implanon = Nexplanon
 +
***A source of estrogen (etonogestrel)
-
–
+
====Mechanism of Hormonal contraceptions====
-
Left in place for 6-8 hrs post-coitus
+
*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
 +
===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
 
-
Diaphragms
+
*Very low failure rate: 0.2-0.8%
-
 
-
Diaphragm6
 
-
Diaphragm6
 
-
Diaphragm3
 
-
The Sponge
+
*Contraindications:
 +
**Recent PID
 +
**Suspicion of genital cancer
 +
**Pelvic TB
-
•
 
-
Small, disposable; contains spermacide
 
-
•
+
===Emergency Contraception Options===
-
Once in place, can provide contraception for 24hrs no mater how often coitus occurs
+
*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.
-
•
 
-
Today Sponge off US market in 1995 but reintroduced in May ‘09
 
-
•
+
*Indications:
-
Other Brands available worldwide
+
**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
-
•
 
-
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
-
elaine01-black_dress
+
*Yuzpe method:
 +
**No better and maybe less effective than just using progestin alone.
 +
**High side effects (n/v)
 +
**Requries prescription.
-
Hormonal Contraceptives
 
-
•
 
-
OCPs
 
-
•
+
===Permanent Birth Control===
-
Injectable –
+
*Vasectomy
-
Combined Injectable Contraceptives (CICs)
+
**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.
-
–
+
==Elective Abortions==
-
Depo-Provera
+
*'''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
-
–
 
-
Norplant
 
-
–
+
*Two major methods:
-
Implanon
+
**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
 +
==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
+

Current revision as of 00:25, 3 December 2011

Contents

[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:
    • ?
Retrieved from "http://editthis.info/iusmicm/OBGYN_-_Family_Planning"
Personal tools