Contraception – Overview

C= ontraception – Overview

Analia Castiglioni, MD=

8/2007

Unintended pregnancy is a c= ommon problem. Data from 2001 shows:

· = 49% of all pregnancies were unintended

· = 5% of women 15-44yo had an unintended pregnancy

This highlights the importa= nce of discussing contraceptive options with patients and understanding contracept= ive efficacy: typical (pt nonadherence, inappropriate use) vs = perfect use.

35 year old female p1001 currently on no birth control comes to the office to discuss options of contraception. She reports no med= ical problems and no history of previous surgeries. She is up to date on her pap smear and reports no history of STDs. She does smoke occasionally (1-5 cigarettes/week).

Vitals: 98.6 70 140/90 250lbs Exam: normal=

1. What contraceptive options (categories) are availa= ble and should be discussed? Natural fam= ily planning, Barrier methods (condoms, diaphragm, cervical cap, spermicides), Estrogen+Progesterone methods, Progesterone methods, Intrauterine devices, permanent sterilization (male and female).

2. What f= actors should be considered when selecting a contraceptive method for your patient= ?

Patient characteristics (tobacco use), Efficacy (see = table at the end), Convenience, Duration of action, Reversibility and return to fertility, Effect on uterine bleeding, Frequency of side effects and adverse events, Affordability, Protection against STI’s and Presence of other medical conditions (migraines, HTN, CAD, DVT/hypercoagulability, etc). Spec= ific WHO guidelines for several conditions available.

Contraceptive counseling tool: the top 10 questions that facilitate contraceptive counsel= ing

(Uptodate 2007)

1. What are your contraceptive goals? Do you ever plan to get pregnant? When?

2. Are you currently having sex with a male partner?

3. Have you tried any contraceptive methods? If so, which one(s)?

4. What did you like/dislike about the method(s)?=

5. Are you a good pill taker?

6. For user-controlled methods, how often did you forget to = use the method?

7. Are there any methods you have heard about and would like= to try?

8. How important is spontaneity of use?

9. Is protection from sexually transmitted infections import= ant considering your life situation?

10. Is cost an issue? Does your health insurance plan cover = any contraceptive method?

Barrier Methods:

Condoms: efficacy is user dependent, male c= ondom most effective when used with vaginal spermicide (spermicidal coated condoms not recommended, ^ UTI in females, not better than regular one= s). Potential latex allergy. Female condoms also available. **Major advant= age is protection against STI’s (HIV, GC, chlamydia, thrichomonas, hepatitis) most data on male condom. Less effective against HSV, HPV, syphilis and chancroid (skin transmission).
Diaphragm and cervi= cal cap: Not very popular. R= equire fitting, must be used with spermicide, need to remain in place 6-8h post-intercourse. Not recommended for women at high risk for HIV or HI= V+ as they do not appear to prevent transmission.
Sponge: disc containing 1000mg of nonoxyno= l-9, it is moistened in tap water before insertion, can be left in place 24 hours. No Rx/fitting needed, less effective than diaphragm, not very u= sed.
Lea Contraceptive: = cup shaped, pliable silicone bowl.= As sponge it is OTC, not protective from STI’s. Not a popular metho= d.

Sterilization: (although potentially reversible these methods should be considered permanent)

Tubal ligation: prevents pregnancy by occluding or disrupting tubal patency. Different methods used depending on patient, postpartum vs not, etc. Ectopic pregnancy risk: 7.3 per 1000 pts over = 10 yrs (younger age <30 at time of procedure, bipolar coagulation meth= od highest risk). Decr risk of ovarian cancer has been described.=

Vasectomy (ligation of vas deference): safe, = simple procedure under local anesthesia. An additional method should be use u= ntil semen analysis done (8 weeks or 20 ejaculations post procedure). Highly effective. May ^ risk kidney stones, no proven effect on prostate/test= ic ca.

Hormonal Methods:

3. What are the specific types of hormonal contracept= ion methods available in the Uni= ted States?

Combined estrogen/progesterone contraception: OCPs, Ortho-Evra Patch, Nuva = Ring

Progesterone-only contraception: Progesterone only pills (Mini pill), Depo-Provera injections, Contraceptive implants (Implanon, Jadelle), Levonorgestrel= IUD (Mirena IUD), Plan B emergency contraceptive. (See individual efficaci= es in table below)

4. Which hormone is responsible for the primary contraceptive effect? Mechanism of action?

Estrogen: 1) prevents the recruitment of the dominant follicle by suppressing FSH
= 2) allows for reduction of progesterone dose by recruitment of progesterone receptors,

= 3) minimizes side effect of break through bleeding by stabilizing the endometr= ium

Progesterone: 1) prevents ovulation by suppression of LH surge

= 2) thickened cervical mucus impedes sperm penetration into the upper genital tract.

= 3) produces an atrophic endometrium that is less receptive to implantation.

= 4) impairs secretion and peristalsis within fallopian tubes<= /p>

4. How does the mechanism of action differ between DepoProvera vs mini-pill and Implants vs

levonorgestrel IUD?

Amount of progestin in mini Pill and Implants = are very low and not sufficient to consistently suppress ovulation (up to 40% w= ill still ovulate). Lack of estrogen does not prevent follicular recruitment and may be associated with symptomatic functional ovarian cysts. Contraceptive efficacy is more dependent on the endometrial and cervical mucus effects. Patients should be counseled about the importance of taking the minipill at= the same time daily (cervical mucus thickening requires 2-4 hours and impermeability diminishes about 22 hours after the administration and is go= ne after 27 hours

DepoProvera pr= ovides a large progestin dose, suppresses the LH surge within the 1st 24 hours of administration (much like the emergency contraceptive pill Plan B) with effective contraception for 12 weeks and impaired ovulation up to 1 ye= ar.

Levonorgestrel IUD does not release sufficient progestin systemically to effectively prevent t= he

LH surge and ovulation. Its main contraceptive effect= is similar to the copper T IUD, causing a sterile

inflammatory response (spermicidal effect) within the uterus. Additionally, the local release of

progestins causes thickening of the cervical mucus, progestin effect on the fallopian tubes and

endometrium and anovulation in 5-15% of the treatment cycles.

5. What are other advantages of using each met= hod other than providing contraception? = All

hormonal contraceptives decrease menstrual blood loss, anemia, dysmenorrhea, ectopic pregnancy, and

incidence of PID,

&#= 8226; Combined estrogen and progesterone methods: regulates menses, can manipulate timing/frequency,

òovulatory pain (mittelschmerz), ovulatory bleeding in anticoagulated patients, androgen si= de effects (acne, hirsutism) by increasing SHBG, benign breast disease, risk of endometrial cancer (20% after 1 yr use, 60% after 4 yrs use) with protection lasting 30 yrs beyond last use, decreased risk of ovarian cancer=

(50% after 5 yrs of use, 80% after 10 years of use) w= ith protection lasting 30 years after last use.

&#= 8226; Progestin-only pills: rapid return to fertility, good option for breastfeeders and women in whom

estrogen-containing options can’t be used, poss= ible protection against endometrial cancer, and 20%

are amenorrheic,

&#= 8226; Depo-Provera: = amenorrhea (50% after 1 yr of use, 80% after 5 yrs of use), improvement in<= /span>

endometriosis, ò sickle cell crises by up to 70%, good option for breastfeeders and women

in whom estrogen-containing options can’t be us= ed, protection against endometrial cancer and

possibly ovarian cancer

&#= 8226; Mirena IUD: am= enorrhea (20% after 1 year of use, 60% at 5 yrs of use), good option for<= /span>

breastfeeders and women in whom estrogen-containing o= ptions can’t be used

6. What are some disadvantages of each method?= None protect against STDs*.

&#= 8226; Combined estrogen and progesterone methods: all ñ risk of thromboembolic events. Less serious effects include nausea, breast tenderness, headaches, = breakthrough spotting (more common in the first few cycles), scant or missed menses, òlibido or anor= gasmia (exact mechanism is unknown - possible due to incr. SHBG resulting in decr.= Free androgens), and possible weight gain. OCPs have been associated with hepatocellular adenomas. Label warning on patch-decrease efficacy in wt >= ;198 lbs.

&#= 8226; Progesterone only pills: irregular menses in wo= men NOT breastfeeding (40% with regular cycles, 40% with short irregular cycles, 20% with amenorrhea), and òefficacy if not taken at same time each day due to low serum levels of progestin.

&#= 8226; Depo-Provera: = irregular menses, hypoestrogenism (dyspaurenia, hot flashes), decr. libido, delay in<= o:p>

return of fertility, reversible decrease in bone mine= ral density, progressive weight gain (5.4 lbs in 1st

year, 16.5 lbs after 5 yrs),

&#= 8226; Mirena IUD: Va= ginal spotting/bleeding likely in first few months after insertion, spontaneous

expulsion.

References:

1. www.managingcontraception.com

2. Speroff. Clinical Gynecologic Endocrinology and Infertility. Sixth Edition

3. Uptodate 2007

©2007 UpToDate^®

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Pregnancy ra= te (percent) during first year of use

Typical use=

Perfect use=

Cervical cap

Previous births

32

26

No previous birth

16

9

Condom

Male

15

2

Female

21

5

Diaphragm with spermacide

16

6

Sponge

Previous births

32

20

No previous births

16

9

Fertility awareness

Cervical murus

22

3

Symptothermal

13-20

2

Calendar (rhythm)

13

5

Standard days

12

5

Lactational amenorrhea*

5

<2

Withdrawal

27

4

Depot-provera

3

<1

IUD

Copper T or Mirena

<1

<1

Patch

8

<1

OCPs

Progestin only or combination estrogen-progestin

8

<1

Ring

8

<1

Female sterilization

<1

<1

Vasectomy

<1

<1

Emergency contraception

Pills

Pregnancy rate decreased by 75 to 89 percent, depending = on the regimen used (higher pregnancy rate is for combined estrogen-progestin pills, lower pregnancy rate is for levonorgetrel alone)

IUD

Pregnancy rate decreased by 99 percent=

No method

85

85

* Rate reflects cumulative pregnancy r= ate in the first 6 months following birth.