James L. Hubbard, DO

Fellow ACOOGCarolina Ob/Gyn, Rock Hill, SC

Chief of Staff, Piedmont Medical Center

Board of SC Medical Examiners

Current Contracepti

veChoices

History of Contraception

Ancient EgyptEarliest recorded contraception dates back

3,000 years.Smooth pebbles were inserted into the uteri of

camels to prevent them from getting pregnant on long trips across the desert.

Suppositories made from elephant and crocodile dung were inserted prior to intercourse, which has a high concentration of bile salt. Therefore the pH of this dung is the most acidic in the animal kingdom and was both a blocking agent and spermicide.

Other Ancient CulturesThe Talmud, an ancient Hebrew text, recommends

manually removing the semen and douching with soap and vinegar.

Chinese scrolls recommend dabbing the cervix with a mixture of olive oil and honey, inhibiting both fetal growth and ovulation.

Ancient Greece used mixture of acacia gum, honey, and seed wool which breaks down to lactic acid.

In India, wild carrot seed was used as a post-coital contraceptive. Studies have shown that these seeds are a spermicide.

More Recent HistoryCondoms date back to 1546 made from

everything from animal intestine to animal skins to okra pods. The term condom is thought to have originated from a Dr. Condom, a personal physician of King Charles II.

Origins of the pill came about by chance. A researcher discovered certain tribes in Mexico were eating a wild yam which seemed to act as a contraceptive. On analysis he was able to extract progesterone from these yams and formulate the first pill.

Barrier Methods

CondomsMale and female.Failure rate if used perfectly is 2% in male,

5% in female.Typical failure rate is 15% for male, 21% for

female.Protection against STDs.

Cervical CapsFailure rate is 29%.Can stay in place up to 48 hours.Recommend pap 3 months after initial use

due to increase chance of dysplasia which drops off after a year.

Does not protect against STDs.May need to be refitted postpartum.

DiaphragmsPerfect use failure rate 6%, actual 16%.Requires fitting, increases UTI.Recommended use with spermicide.Some protection against STDs.

SpermicideUsed independently, failure rate 29%.Use with condoms no longer recommended.

ESTROGEN AND PROGESTREONE

CONTRACEPTIVES

Combination PillHas been available since the 1960’s. Most

contain Ethinyl estrogen and at least 7 different progestins.

Combination PillMechanism of suppressing ovulation. Perfect

use failure rate is 0.3%, actual 6%.Advantages: shorter, lighter scheduled

menses, no ovulation pain, sexual spontaneity.Generic vs. brand name? FDA allows

variability in potency in generics of -20% to +25% in dosing of generics .

Current brand oc available: Loestrin 24 Fe, Lo Loestrin Fe, Beyaz, Natazia, Lybrel, Seasonique.

Controversy around Drospirenone Drospirenone: a derivative of spironolactone

found in Yasmin, Yaz, and Beyaz.Decreasing androgen side effects.Hyperkalemia (renal insufficiency, hepatic

dysfunction, and adrenal insufficiency).Increased risk of blood clots.

Choosing OCs for your patientNew start (Lo loestrin)Endometriosis (Seasonque, Lybrel)Menstrual migraines (Seasinque, Lybrel)Androgen excess/ PCO (Beyaz) Breastfeeding (Lo loestrin)Breakthrough bleeding (higher dose oc,

Natazia)Premenopausal (Lo loestrin)

NuvaRing®

• Very low dose

120 g/day etonogestrel

15 g/day ethinyl estradiol

• Flexible transparent ring

Outer diameter: 54 mm

Cross-sectional diameter: 4 mm

• One ring per cycle 3 weeks ring-in

1 week ring-free

54 mm

4 mm

Ortho Evra PatchHigher doses of active estrogen in the blood

stream than previously thought could increase the chance of DVT.

Less effective in women 190 lbs or above.

LunelleMonthly injectable combination birth control.No longer available since 2002 due to lack of

potency assurance.

PROGESTERONE ONLY CONTRACEPTIVES

Pills (Mini Pills)Candidates for usage

Breast feedingHistory of DVTOver 35 years of ageSmokersHistory of HTN

Depo-Provera injectionWeight gainDUBFertility post-useDue to decrease in bone mineral density

(BMD) in users, the FDA recommends other forms of bc be used after 2 years of consecutive use if other forms of bc available.

Implanon Follow-up to Norplant, which was

discontinued in 2002.Single implant 4cm long and 2mm wide.Placed under the skin of the upper arm.Used for 3 years.

INTRAUTERINE CONTRACEPTION

ParaGard (Copper T)Made from polyethylene with a solid sleeve of

copper.Introduced in 1984.Primary mechanism of action is as a spermicide

(releasing toxic cooper ions, causing phagocytosis, and causing crx mucous thickening).

20% of physicians still believe it has an abortive effect.

Biggest benefits are its long term use (10 years) and its non-use of steroids.

PID, pregnancy, perforation.

Mirena5-year IUD impregnated with progesterone.Similar mechanism of action as the ParaGard

with anovulatory effect.FDA approved for the treatment of DUB and

perhaps premenopausal symptoms.Use in nulliparous and young patients.

TUBAL LIGATION AND OCCLUSION

Failure rates of tubal methodsSilicon bands 1.8%Partial salpingectomy 2.0%Bipolar cautery 2.5%S-ring (hulka) clip 3.7%Filshie clip 0.9%

Intrauterine Tubal Occlusion Essure

Uses a nickel titanium spring coil with polyethylene fibers. These fibers cause chronic inflammation and scarring.

Can be placed hysteroscopically in an outpatient setting with local anesthesia.

May be preferred in obese pts, pts wishing no scars, and pts with hx of adhesions.

Disadvantages are 3 month waiting period followed by histerosalpingogram, difficult to visualize ostia, perforation of tube, or tubal spasms.

Intrauterine Tubal Occlusion

Intrauterine tubal occlusion Adiana

Similar to Essure, is placed hysterscopically, but uses a silicone pellet the size of a grain of rice and long with low level radiofrequency energy to create a superficial lesion in the tube.

This technique also needs to have a follow up histersalpingogram 3 months post procedure.

Intrauterine Tubal Occlusion

THE FUTURE OF CONTRACEPTION

Progesterone only vaginal ringLasts for a full year.

Gyenfix Copper IUD6 sleeves of copper on a string embedded in the

fundus.Lasts 3 years and in use in Europe.

FibroplantProgestin-releasing fiber fixed to the uterine

wall.Norplant II

Similar to original Norplant but only 2 rods.Lasts up to 3 years.

Contraceptive sprayProgesterone delivered to your forearm.Uses technology similar to EvaMist.

Once a month pillUses technology similar to Boniva.

Quinacrine sterilizationInvolves insertion of 7 pellets into the uterus

with an IUD-type tool.Repeated 2 to 3 months in a row.This causes tubular scarring.Currently used in some third world countries,

it remains controversial due to lack of knowing if there are any long-term side effects.

The End