OBGYN - Family Planning
From Iusmicm
Contents |
Contraception
Objectives
- Review basic statistics concerning population growth and pregnancy rates
- Review basic contraceptive options
- 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).
- 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.
- 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.
Abortion rates
- The United States of America aborts 22.9 of each 1000 fetuses.
- Australia: 22.2 / 1000
Birth Control: Mode of Action
- There are two categories of birth control
- There are many options:
- OCPs
- Norplant
- Depo-Provera
- Condoms
- Diaphragm
- Foam
- Rhythm
- IUDs
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Why Counseling is Important
• Abortion Rates, by age group, per 1000 births (2000 Stats)
• 10% of women don’t use contraception – These account for 53% of unintended pregnancies
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Unintended%20pregnancy
prams_1
prams_2
General Mode of Action
• Prevention of Conception – OCPs, Norplant, Depo-Provera, Condom, Diaphragm, Foam, Rhythm, IUDs
•
Prevention of Implantation –
IUDs, “Morning After Pills”
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Worldwide Use of Contraceptive Types
• Prevalence of Selected forms of Contraception in Developed and Developing Countries
• Projected Use of Contraception in Developing Countries for 2000
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Barrier Methods
• Spermacides
• Condoms
• Diaphragm & Cervical Caps
• Sponges
Spermacides
• Active Ingredient – Either Nonoxynol 9 or Actoxynol-3
•
Failure Rate –
15 to 35%
•
Patient Compliance –
HIGH
Spermacide1
Condoms
• Male Condom – Slippage/Breakage Rate: 5-8%
– Failure Rate: 5-15%
•
Female Condom –
Slippage/Breakage Rate: 3%
– Failure Rate: 5-15%
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FCondom
FCondom2
Copy of FCondom7
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Diaphragms
• Mechanism of Action
• Failure Rate: 10-20%
• Benefits
• Precautions
• Patient Compliance: – Inserted 1 hr before
– Left in place for 6-8 hrs post-coitus
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Diaphragm1
Diaphragms
Diaphragm6
Diaphragm6
Diaphragm3
The Sponge
• Small, disposable; contains spermacide
• Once in place, can provide contraception for 24hrs no mater how often coitus occurs
• Today Sponge off US market in 1995 but reintroduced in May ‘09
• Other Brands available worldwide
• Failure Rate: 26-40%
elaine01-black_dress
Hormonal Contraceptives
• OCPs
• Injectable – Combined Injectable Contraceptives (CICs)
– Depo-Provera
– Norplant
– Implanon
•
New Types –
Ring
– 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
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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%
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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
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03
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Conclusions
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