Contraception for medicines Contraception

Contraception

1. CONTRACEPTIONCONTRACEPTION
Basim Abu-Rafea, MD, FRCSC, FACOG
Assistant Professor & Consultant
Obstetrics & Gynecology
Reproductive Endocrinology & Infertility
Advanced Minimally Invasive Gynecologic Surgery
Department of Obstetrics & Gynecology
King Khalid University Hospital
King Saud University

2. ObjectivesObjectives
Describe the advantages, disadvantages, failure
rates, and complications associated with the
following methods of contraception
–Sterilization
–Oral steroid contraception
–Injectable steroid contraception
–Implantable steroid contraception
–Barrier methods
–Natural family planning

3. AbstinenceAbstinence
Mechanism: excludes sperm from female
reproductive tract
Effectiveness: 0% failure rate
Ideal for adolescents at high risk for
pregnancy and STD’s including HIV
Complications: None

4. Breastfeeding:Breastfeeding:
Lactation Amenorrhea Method (LAM)Lactation Amenorrhea Method (LAM)
Mechanism: Suckling causes increased prolactin,
which inhibits estrogen production and ovulation
2% typical use failure rate in 1
st
six mos.
Candidates:
–Amenorrheic women < 6 mos post-partum who exclusively
breastfeed (90% of nutrition is breast milk)
–Women free of blood-borne infections
–Women not on drugs that could effect baby
Kennedy KI. et al., Contraceptive Technology.2004

5. LAM ComplicationsLAM Complications
Breastfeeding may increase the risk of mastitis
Return of fertility or ovulation may precede
menses.
33-45% ovulate during 1
st
3 months.
Encourage backup form of contraception

6. Barrier Methods:Barrier Methods:
Male CondomsMale Condoms

7. Barrier Methods:Barrier Methods:
Male CondomsMale Condoms
Sheaths of latex, polyurethane, or natural membranes that
may or may not have spermicide.
Mechanism: Barrier that prevents sperm and infections from
entering vagina.
Effectiveness: 15% typical use failure rate.
Candidates:
–Couples not in mutually monogamous relationships
–Couples in which one partner has an STD/HIV
–Couples starting other types of birth control
–Couples who can’t use hormonal methods
Warner DL, et al. Contraceptive Technology. 2004

8. Barrier Method:Barrier Method:
Female CondomFemale Condom
Disposable single use polyurethane sheath placed in
vagina.
Flexible movable inner ring at closed end used to insert
into vagina.
Flexible outer ring to cover part of the introitus.
Mechanism: Prevents passage of sperm and infections
into the vagina.
Failure rate is high at 21% with typical use.
Hatcher et al. Managing Contraception.2004

9. Barrier Method:Barrier Method:
Female CondomFemale Condom
Candidates the same as for male condoms.
Female condom is reusable only if the partner does
not have an STD.
Disadvantages:
–Awkward and difficult to place
–Most users do not enjoy using female condom (88% of
women and 91% of men)
–Many couples complain about noise of condom

10. Female Condom: “Reality”Female Condom: “Reality”

11. Barrier Method:Barrier Method:
Cervical CapCervical Cap
Thimble- shaped latex rubber device which
has an inner ring that provides suction to
keep cap on the cervix.
Spermicide is placed inside the cap before
being placed on the cervix to kill sperm.
4 sizes: 22, 25, 28, 31 mm.
Mechanism: barrier that prevents sperm
migration into cervical canal

12. Barrier Method:Barrier Method:
Cervical CapCervical Cap
Advantages:
–May decrease risk of GC, Chl, and PID
–Can be placed 6 hours prior to intercourse
–Can remain in vagina up to 48 hours for multiple
acts of intercourse
Disadvantages:
–No protection against HIV
–Poor fit especially in parous women
–Failure Rate: As high as 32% in parous women and
16% in nulliparous women
–Patient must leave in place at least 8 hours after
intercourse before removing

13. DiaphragmDiaphragm

14. Barrier Method:Barrier Method:
DiaphragmDiaphragm
Latex rubber dome-shaped device that covers
the cervix
Mechanism: prevents sperm from entering
cervical canal
Three types:

Arcing Spring

Coil Spring

Wide Seal

15. Barrier Method:Barrier Method:
DiaphragmDiaphragm
Typical use failure rate: 16% in one year
May reduce risk of GC, Chl, PID
Risks:
No protection from HIV
Difficult to place around cervix
May fall out in women with pelvic relaxation
May cause vaginal erosions & infections
May cause reaction in latex allergic
Toxic Shock Syndrome
Urinary Tract Infections

16. SPERMICIDESPERMICIDE
Most common is nonoxynol-9
Available in creams, films, foams, gels,
suppositories, sponges, and tablets
Best when used with barrier methods
29% typical use failure rate when used alone
Provides no protection against STD’s and HIV

17. Emergency Contraception (EC)Emergency Contraception (EC)
Any method used after unprotected or inadequately
protected sexual intercourse
Three types of EC available in the United States:
High dose progestin only ( Plan B)
Yuzpe method- 13 different combined oral contraceptives (Preven)
Copper IUD ( Paragard)
Dickey. Managing Contraceptive Pill Patients, 2002

18. Emergency Contraception (EC)Emergency Contraception (EC)
Mechanism: Prevents fertilization and implantation.
Counsel patients that this method does not abort a pregnancy that is
already implanted
Common in women after an assault or rape
Most women will have a cycle 21 days after completing emergency
contraception
If patient does not have a cycle in 21 days, it is important to check a
pregnancy test

19. Emergency Contraception (EC)Emergency Contraception (EC)
High dose progestin-only (Plan B):

1.5mg Norgestrel at one time or in divided doses.

Divided Dose: 1
st
dose within 72-120 hours of intercourse. 2
nd

dose 12 hours later.

One dose: Both tablets within 72-120 hours of intercourse
Glaser A. Emergency post-coital contraception, New England Journal of Medicine, 1997.

20. Emergency Contraception (EC)Emergency Contraception (EC)
Yuzpe Method (Preven)
–100mcg of ethinyl estradiol and 0.50 mg of
levonorgestrel in each dose.
–1
st
dose within 72 hours of intercourse and 2
nd

dose 12 hours later

21. Emergency Contraception (EC)Emergency Contraception (EC)
Copper IUD
–Place within 5 days of unprotected coitus.
–This is usually given to women who plan to use
the IUD for long term birth control.
–Interferes with implantation after fertilization.

22. Intrauterine DevicesIntrauterine Devices

23. Intrauterine Devices (IUDs)Intrauterine Devices (IUDs)
Copper IUD (Paragard T 380 A)
–Copper is a spermicide that
inhibits sperm motility and
acrosomal enzyme action
–Lasts 10-12 years
–May increase bleeding and
dysmenorrhea
–Typical use failure rate is 0.8%
Mirena (Levonorgestrel)
–Increases thickness of cervical
mucus to inhibit sperm migration
–Lasts up to 7 years
–Improves menorrhagia by 90% in
most patients
–Causes amenorrhea in many users
–Typical use failure rate is 0.1%

24. IUDIUD
Good for women in mutually monogamous
relationships
Risks:
–Increased risk of PID within 1
st
20 days
–Uterine perforation
–Fainting with insertion
–Expulsion
–Unexpected pregnancy following poor placement

25. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Mechanism:
–Blocks ovulation
–Thickens cervical mucus
–Thins the endometrial lining

26. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Ethinyl estradiol is the most commonly used estrogen in OCP’s
There are multiple forms of progestins
Monophasic: same amount of hormone in each active tablet
Multiphasic: varying amounts of hormone in each active pill
Most OCP’s have 21 active pills and 7 placebo pills

28. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Alternate Formulations:
–Seasonale: 84 consecutive hormonal pills followed by
7 days of placebo
–Ovcon-35: chewable pills
–Yasmin: Drospirenone which is anti-androgenic and
anti-mineralcorticoid

29. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Non-contraceptive Uses of OCPs
–Dysfunctional uterine bleeding
–Dysmenorrhea
–Mittelschmerz
–Endometriosis prophylaxis
–Acne and hirsutism
–Hormone replacement
–Prevention of menstrual porphyria
–Functional ovarian cysts

30. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Advantages:
–Less endometrial cancer (50% reduction)
–Less ovarian cancer (40% reduction)
–Less benign breast disease
–Fewer ovarian cysts (50% to 80% reduction)
–Fewer uterine fibroids (31% reduction)
–Fewer ectopic pregnancies
–Fewer menstrual problems
 
          --more regular
 
          --less flow
 
          --less dysmenorrhea
 
          --less anemia
–Less salpingitis (pelvic inflammatory disease)
–Less rheumatoid arthritis (60% reduction)
–Increased bone density
–Probably less endometriosis

31. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Disadvantages
Spotting especially in 1
st
few months
May decrese Libido
Requires daily pill intake
No protection against STD’s and HIV
Possible weight gain
Post-contraception amenorrhea

32. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Absolute Contraindications:
–Thromboembolic disorder (or history thereof)
–Cerebrovascular accident (or history thereof)
–Coronary artery disease (or history thereof)
–Impaired liver function (current)
–Hepatic adenoma (or history thereof)
–Breast cancer, endometrial cancer, other estrogen-dependant malignancies
–Pregnancy
–Undiagnosed vaginal bleeding
–Tobacco user over age 35

33. Combined Oral ContraceptivesCombined Oral Contraceptives
(Estrogen & Progestin)(Estrogen & Progestin)
Relative Contraindications
–Migraine headaches, esp. worsening with pill use
–Hypertension
–Diabetes mellitus
–Elective surgery (needs 1 to 3 month discontinuation)
–Seizure disorder, anticonvulsant use
–Sickle cell disease (SS or sickle C disease (SC)
–Gall bladder disease.

34. Choosing The Right OCP’sChoosing The Right OCP’s
Endometriosis: Choose a pill with a strong progestin to create a
pseudo-pregnancy state
Functional Ovarian Cysts: High dose monophasic pill may be
more effective
Androgen excess: Choose a pill with high estrogen/progestin
ratio to reduce free testosterone and inhibit 5 reductase activity
Breastfeeding: Progestin -only pill

35. Transdermal: Ortho EvraTransdermal: Ortho Evra
Delivers 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin
daily
Takes 3 days to achieve a steady state of hormone in the blood stream
Patch is replaced once per week for 3 consecutive weeks
Worn on abdomen, buttocks, upper outer arm, or upper torso
Do not place on the breast

36. Transdermal: Ortho EvraTransdermal: Ortho Evra
Advantages:
–Only has to be replaced once per week
–May be taken continuously
Disadvantages:
–May slip off- provide pt. with an emergency patch
–Patch may be less effective in women who are > 198 pounds

37. Vaginal Contraceptive Ring: NuvaRingVaginal Contraceptive Ring: NuvaRing
Combined hormonal contraception consisting of a
5.4 cm diameter flexible ring
15 mcg ethinyl estradiol and 120 mcg of
desogestrel
Mechanism: suppresses ovulation
Typical use failure rate: 8%

38. Vaginal Contraceptive Ring: NuvaRingVaginal Contraceptive Ring: NuvaRing
Place in vagina and remove after 3 weeks
Allow withdrawal bleeding and replace new ring
Steady low release state
Advantage is patient only has to remember to insert
and remove the ring 1x/ month
May be placed anywhere in the vagina

39. Depo ProveraDepo Provera
150 mg IM every 3 months
Contraceptive level maintained for 14 weeks
Failure Rate: 3% typical use failure rate
Mechanism:
–Thickens cervical mucus
–Blocks the LH surge
–Initiate treatment during the first week of menses

40. Depo ProveraDepo Provera
Advantages
–Long acting
–Estrogen-free
–Safe in breast-feeding
–Can be used in sickle-cell
disease and seizure disorder
–Pt. does not have to take daily
–Increases milk quality in
nursing mothers
Disadvantages
–Irregular bleeding (70% in
first year)
–Breast tenderness
–Weight gain
–Depression
–Slow return of menses after
stopping use
–Decreases HDL cholesterol

41. Female SterilizationFemale Sterilization
Interrupts the patency of fallopian tubes-
thereby preventing fertilization
Failure rate: Depends on method used -ranges
from 0.8-3.7%
May be performed through a mini-laparotomy
incision , laparoscopically, or transcervically

42. Female SterilizationFemale Sterilization

43. Male SterilizationMale Sterilization

44. Male SterilizationMale Sterilization
Vasectomy: ligate or cauterize the vas deferens
Mechanism: interrupts vas deferens preventing passage of sperm
into seminal fluid
May be done under local anesthesia
Cheaper than female sterilization
Failure rate: < 0.15%
Use contraception until completely azospermic for two consecutive
sperm counts ( usually takes 12 weeks or 10-20 ejaculations)
Does not affect ability to have an orgasm