contraception basim abu-rafea, md, frcsc, facog assistant professor & consultant obstetrics &...
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CONTRACEPTIONBasim Abu-Rafea, MD, FRCSC, FACOGAssistant Professor & ConsultantObstetrics & GynecologyReproductive Endocrinology & InfertilityAdvanced Minimally Invasive Gynecologic SurgeryDepartment of Obstetrics & GynecologyKing Khalid University HospitalKing Saud University
ObjectivesDescribe the advantages, disadvantages, failure rates, and complications associated with the following methods of contraception
SterilizationOral steroid contraceptionInjectable steroid contraceptionImplantable steroid contraceptionBarrier methodsNatural family planning
AbstinenceMechanism: excludes sperm from female reproductive tract
Effectiveness: 0% failure rate
Ideal for adolescents at high risk for pregnancy and STDs including HIV
Breastfeeding:Lactation Amenorrhea Method (LAM)Mechanism: Suckling causes increased prolactin, which inhibits estrogen production and ovulation
2% typical use failure rate in 1st six mos.
Candidates:Amenorrheic women < 6 mos post-partum who exclusively breastfeed (90% of nutrition is breast milk)Women free of blood-borne infectionsWomen not on drugs that could effect baby
Kennedy KI. et al., Contraceptive Technology.2004
LAM ComplicationsBreastfeeding may increase the risk of mastitis
Return of fertility or ovulation may precede menses.
33-45% ovulate during 1st 3 months.
Encourage backup form of contraception
Barrier Methods:Male Condoms
Barrier Methods:Male CondomsSheaths 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 relationshipsCouples in which one partner has an STD/HIVCouples starting other types of birth controlCouples who cant use hormonal methods
Warner DL, et al. Contraceptive Technology. 2004
Barrier Method:Female CondomDisposable 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
Barrier Method:Female CondomCandidates the same as for male condoms.
Female condom is reusable only if the partner does not have an STD.
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
Female Condom: Reality
Barrier Method:Cervical CapThimble- 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
Barrier Method:Cervical CapAdvantages:May decrease risk of GC, Chl, and PIDCan be placed 6 hours prior to intercourseCan remain in vagina up to 48 hours for multiple acts of intercourse
Disadvantages:No protection against HIVPoor fit especially in parous womenFailure Rate: As high as 32% in parous women and 16% in nulliparous womenPatient must leave in place at least 8 hours after intercourse before removing
Barrier Method:DiaphragmLatex rubber dome-shaped device that covers the cervix
Mechanism: prevents sperm from entering cervical canal
Arcing SpringCoil SpringWide Seal
Barrier Method:DiaphragmTypical use failure rate: 16% in one year
May reduce risk of GC, Chl, PID
Risks:No protection from HIVDifficult to place around cervixMay fall out in women with pelvic relaxationMay cause vaginal erosions & infectionsMay cause reaction in latex allergicToxic Shock SyndromeUrinary Tract Infections
SPERMICIDEMost 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 STDs and HIV
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
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
Emergency Contraception (EC)High dose progestin-only (Plan B):
1.5mg Norgestrel at one time or in divided doses.
Divided Dose: 1st dose within 72-120 hours of intercourse. 2nd 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.
Emergency Contraception (EC)Yuzpe Method (Preven)
100mcg of ethinyl estradiol and 0.50 mg of levonorgestrel in each dose.
1st dose within 72 hours of intercourse and 2nd dose 12 hours later
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.
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%
IUDGood for women in mutually monogamous relationships
Increased risk of PID within 1st 20 daysUterine perforationFainting with insertionExpulsionUnexpected pregnancy following poor placement
Combined Oral Contraceptives(Estrogen & Progestin)Mechanism:
Blocks ovulationThickens cervical mucusThins the endometrial lining
Combined Oral Contraceptives(Estrogen & Progestin)Ethinyl estradiol is the most commonly used estrogen in OCPs
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 OCPs have 21 active pills and 7 placebo pills
Combined Oral Contraceptives(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
Combined Oral Contraceptives(Estrogen & Progestin)Non-contraceptive Uses of OCPs
Dysfunctional uterine bleedingDysmenorrheaMittelschmerzEndometriosis prophylaxisAcne and hirsutismHormone replacementPrevention of menstrual porphyriaFunctional ovarian cysts
Combined Oral Contraceptives(Estrogen & Progestin)Advantages:
Less endometrial cancer (50% reduction)Less ovarian cancer (40% reduction)Less benign breast diseaseFewer ovarian cysts (50% to 80% reduction)Fewer uterine fibroids (31% reduction)Fewer ectopic pregnanciesFewer menstrual problems --more regular --less flow --less dysmenorrhea --less anemiaLess salpingitis (pelvic inflammatory disease)Less rheumatoid arthritis (60% reduction)Increased bone densityProbably less endometriosis
Combined Oral Contraceptives(Estrogen & Progestin)Disadvantages
Spotting especially in 1st few months
May decrese Libido
Requires daily pill intake
No protection against STDs and HIV
Possible weight gain
Combined Oral Contraceptives(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 malignanciesPregnancy Undiagnosed vaginal bleeding Tobacco user over age 35
Combined Oral Contraceptives(Estrogen & Progestin)Relative Contraindications
Migraine headaches, esp. worsening with pill use Hypertension Diabetes mellitusElective surgery (needs 1 to 3 month discontinuation) Seizure disorder, anticonvulsant use Sickle cell disease (SS or sickle C disease (SC) Gall bladder disease.
Choosing The Right OCPsEndometriosis: 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 5a reductase activity
Breastfeeding: Progestin -only pill