Contraception

Male Condoms

 

benefits

limitations

success rates

costs

Female Condoms

 

benefits

limitations

• doesn't protect against HPV or herpes

success rates

costs

 

Diaphragm

 

• two step process: need contraceptive jelly
• must be left in for 6 hours after
• difficult to use in women who have had children
• can become damaged
• 94%/84%

 

Fertility Predictor

post-ovulation, symptothermal method, cervical mucous, calendar - require a woman to know her body really well and pay close attention. There is maybe a 10 day window of safety

benefits

limitations

success rates

costs

Intra Uterine Devices

copper-containing

• Nova T, slimline
• 99% effective
• can be left in from 30 months up to years

Mirena - progesterone-containing ; makes bleeding lighter

• small amounts of progesterone
• 99.9%
• lasts up to 5 years

• can cause infections in women with multiple partners
• difficult to insert in nulliparous women

Relative contraindications

• pregnancy
• current or recent PID
• immediate post-septic abortion
• unexplained vaginal bleeding

Oral Contraception

Oral contraceptives (OCs) are very effective, with a risk of pregnancy of 6-8% with typical use and of about 1% with perfect use (Petitti, 2003). Normally a combination of estrogen and progesterone.

 

Uses of oral contraceptive pills include (Petitti, 2003, Black et al, 2004):

• birth control
• control of dysmenorrhea and menorrhagia
• control of acne
• hirsuitism
• reduced hot flashes in perimenopausal women
  
• decreased risk of endometrial cancer, ovarian cancer, ovarian cysts, and fibroids, with possibly decreased risk of osteoporosis, endometriosis, and colorectal cancer

 

Selecting the product

Combined OCs contain two hormones - estrogen and progestin. Estrogen is usually ethinyl estradiol (EE) at a dose of 20-50 ug. Nausea or breast tenderness may be reduced by using a low-dose EE pill.

Progestins may be monophasic, biphasic, or triphasic, describing weekly variations in dose. Selective progestins have little or no androgenic activity, and these may be helpful for patients with acne, oily skin, hirsuitism, mood swings, or premenstrual symptoms. Progestins include:

• ethynodiol diacetate
• levonorgestrel
• norestrel
• norethindrone
• desogestrel (selective)
• norgestimate (selective)
• drospirenone
  

Progestin-only contraceptives contain norethindrone. They are useful when estrogen is contraindicated, for example in smokers over 35, in breastfeeding women, or in women with hypertension, migraine + aura, or a history of DVT.

A monophasic pill us helpful if the cycle is heavy.

Starting the pill

There are a number of ways of beginning OC. It may be started immediately in the office after ruling out pregnancy, on the first day of the cycle, or the fifth day of the cycle. If the pill is started after the fifth day, alternative contraception must be used for 7 days.

A recheck should be done within 3 months to assess, especi

 

Regimens

Pills may be taken on 21 or 28 day cycles. In the case of 28 day cycles, the last 7 days are sugar or 'dummy' pills, used to maintain consistency in a woman's routine.

Continuous use is also feasible, and is often done for women who have dysmenorrhea, mood swings, or would like to avoid periods. Breakthrough bleeding often occurs, but decreased over time.

Progestin only pills need to be taken at the same time daily, are taken consistently, and often are accompanied by irregular bleeding.

 

Missed pills

If a woman misses one pill, it should be taken as soon as possible, and the next pill taken at the normal time. If two consecutive days are missed during the 1st or 2nd week, take 2 pills daily for 2 days, then return to one pill daily. Use back-up contraception for one week.

If two consecutive days are missed during the third week, or if three or more pills are missed at any time, discard the pack and immediately start a new pack. Use back-up contraception for one week.

Make it a routine; put the pack by your toothbrush.

Adverse Effects

While OC is very safe, there are a number of adverse effects that may result. These are described below.

common side effects nausea/vomiting headache breakthrough bleeding bloating breast tenderness weight gain

significant complications   stroke, myocardial infarction (with higher concentrations) especially with increased age or smoking   venous thromboembolism rates of 3-4 x increased risk with thrombophilia (ie Factor V Leiden)     increased risk with smoking, age   breast cancer potential very small increase in risk (RR 1.24; CI 1.15-1.33)

other depression weight gain? cholecystitis impaired liver function

 

Contraindications

There are many relative contraindications, and a number of absolutes.

Comprehensive listings may be found as follows: Reproductive Health Access Project, Centres for Disease Control

 

Some of the significant contraindications include:

• pregnancy
• smoker, over age 35
• <six weeks post-partum and breastfeeding
• migraines, especially with aura
• significant diabetes mellitus
• hypertension > 160/100
• current or past breast cancer
• medications: antivirals, anticonvulsants, rifampin
• gallbladder disease
• significant liver disease
• DVT, current or past
• ischemic heart disease
• stroke
• hypercoagulability (inherited thrombophilia)
• major surgery with immobilization

Other Hormonal Methods

Vaginal Ring (Nuva Ring)

• estrogen and progesterone
• placed in vagina for 3 weeks out of 4
• EE (2.6mg) - 15

Depo Provera

• progesterone only injection every 12 weeks
• popular among younger women due to ease of use
• 99.7% if injections are received in time
• recent warnings about bone loss, perhaps more of a problem in younger people with long time use
• effect within 24 hours; amenorrhea (50% 1 yr, 80% 3 yrs)
• side effects: breakthrough bleeding ++

Lunelle

• 99.9% once a month injection of estrogen and progesterone
• only in US

Implanon

• two implantable rods
• only in US
• potential problems getting them out

• 99.7%/ 97%
• many failures are due to missing pills or starting late

 

progesterone-only pill (POP)

good for patients who cannot take estrogen

immediate return to fertility; 10% amenorrhea

 

increases cervical mucous; can cause endometrial atrophy and inhibit

 

Evra: an estrogen/progesterone patch that is worn 3 weeks out of 4

• some controversy around DVT/PE

 

Permanent Methods

• male: 99.85% vasectomy
• female: 99.5% tubal ligation
• Essure: intra-fallopian tube coils that are inserted trans-cervically and induce scarring/closure
  • not covered by MSI
  • not possible for all patients
  • requires dye test to confirm

 

Emergency Contraception

• pills taken within 72 hours of intercourse
• 'Yuzpe' regimen originally used with both estrogen and levonogestrel (synthetic progestin)
• OTC now
• "Plan B" - levonorgestrel: 85% success with less nausea
• IUCD can be inserted within 5 days of intercourse