contraception basim abu-rafea, md, frcsc, facog assistant professor & consultant obstetrics...
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CONTRACEPTIONCONTRACEPTIONBasim Abu-Rafea, MD, FRCSC, FACOG
Assistant Professor & ConsultantObstetrics & Gynecology
Reproductive Endocrinology & InfertilityAdvanced Minimally Invasive Gynecologic Surgery
Department of Obstetrics & GynecologyKing Khalid University Hospital
King Saud University
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
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
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 1st 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
LAM ComplicationsLAM Complications
Breastfeeding 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:Barrier Methods:Male CondomsMale Condoms
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
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
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
Female Condom: “Reality”Female Condom: “Reality”
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
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
DiaphragmDiaphragm
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
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
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
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
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
Emergency Contraception (EC)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)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)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 DevicesIntrauterine Devices
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%
IUDIUD
Good for women in mutually monogamous relationships
Risks:
– Increased risk of PID within 1st 20 days– Uterine perforation– Fainting with insertion– Expulsion– Unexpected pregnancy following poor placement
Combined Oral ContraceptivesCombined Oral Contraceptives(Estrogen & Progestin)(Estrogen & Progestin)
Mechanism:
– Blocks ovulation
– Thickens cervical mucus
– Thins the endometrial lining
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
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
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
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
Combined Oral ContraceptivesCombined Oral Contraceptives(Estrogen & Progestin)(Estrogen & Progestin)
Disadvantages
Spotting especially in 1st few months
May decrese Libido
Requires daily pill intake
No protection against STD’s and HIV
Possible weight gain
Post-contraception amenorrhea
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
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.
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
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
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
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%
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
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
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
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
Female SterilizationFemale Sterilization
Male SterilizationMale Sterilization
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