Chapter 10

Contraception

Historical and Social Perspectives

Evidence of contraception since the beginning
of recorded history
U.S. contraceptive efforts
1800s Comstock laws:
1915: Margaret Sanger
Opened illegal clinic.
The Woman Rebel.

U.S. Supreme Court rulings

Griswold vs. Connecticut (1965)- Married couples.

Eisenstadt vs. Baird (1972) - Unmarried individuals.

Today:Far-Right politics, denying contraceptive to 3rd world. ProLife anti-contraception politics.

Contraception as a contemporary issue

- in the U.S. Allows couples to plan for wanted children,
establish relationship, financial stability
Allows women to pursue professional life with
more freedom
Can increase womens health
Pregnancy itself has health risks, spacing
pregnancies at least 18 months apart results in
better health for both mothers and children

Increased pressure to mandate health

insurance coverage for prescription
contraceptives
Many health insurance companies covered Viagra
before they covered the pill
Coverage has increased, but is still not universal

Sex, politics, & contraception

Many pro-life religious groups oppose contraception
and want to prevent access to it.
Dont see contraception as a way to prevent abortion, but as
a gateway to abortion (American Life League)
Many pro-life groups embrace traditional role of women
staying home raising children as the ideal
Has led to decreased funding for clinics that provide free or
affordable birth control, and a higher rate of abortion.
View access to contraception as a threat b/c it helps women expand
their roles into traditionally male realms of work & politics

Bush administration
Political influence of these groups has increased
Anti-contraception policies have been extended globally
international anti-contraceptive organizations
Bush admins refusal to release $34 million that Congress appropriated
to provide contraception and reproductive health services
internationally

Contraception as a global issue

Helps curtail global population growth & spread of HIV
Most successful way
to reduce population
growth worldwide is
to expand womens
educational and
economic
opportunities
Worldwide, women
w/more education
have fewer children

Different cultures and religions have different views

about contraception
EX: Catholic church forbids contraception (other than
abstinence and cycle-based methods), though 70% of
American Catholics use contraceptive methods forbidden by
the Church

A look at the state of Kerala in India

Primarily rural, similar to rest
of India; income level also
not different from rest of
India
Why does Kerala have such a
low birth rate and infant
mortality rate?
High rate of womens literacy
(85% in Kerala, compared
w/<40% in India on avg)
Higher status for women in
Kerala- women can own land;
rather than having to pay a dowry
to marry a woman off, women in
Kerala bring their families a
brideprice & are considered an
asset to the family

Sharing responsibility in choosing a

birth control method
Sharing responsibility is in the interest of both partners
Can enhance relationship trust
Can be a good way to practice
discussing personal & sexual topics
Women respect men who share
responsibility and often resent
men who do not.
Men shouldnt assume that a
woman is taking care of it
Dealing w/an unplanned
pregnancy is difficult

How to share responsibility

ask about BC before intercourse

read & discuss options together
attend a class or clinic together
share expenses

Choosing a Birth Control Method

things to consider
Effectiveness--statistics show two numbers:

Failure rate: # of women per 100 who become

pregnant after 1 yr. when using a b.c. consistently &
correctly
Typical use failure rate--takes into account improper
or inconsistent use
Factors that contribute to improper use include: lack of
partner involvement, forgetfulness, feeling guilty about sex,
poor communication w/partner, not wanting to appear easy

About half of all unintended pregnancies occur among

women using contraceptives

Cost
Ease of use
Side effects

Effectiveness of birth control methods

Also
see
Table
10.1
p. 268

w/ospermicide

FDA,1997

Using backup methods to increase

contraceptive effectiveness

Backup methods: contraceptive methods used

simultaneously w/another method to support it
Condoms, foam, diaphragm, can all be combined
w/other methods for extra protection
When a backup method might be a good idea:
If on the pill:
During first cycle of the pill
After forgetting 2 or more pills, or after several days of
diarrhea or vomiting when on the pill
First month after switching pill type
When taking medications that can reduce effectiveness of the
pill

During first 1-3 months after IUD insertion

When first learning how to use a new method
To increase overall effectiveness of contraception

Outercourse

is to prevent
pregnancy, not
to protect
Noncoital forms of sexual intimacyagainst STIs

Kissing, touching, mutual masturbation, oral

sex, anal sex
Any type of sexual intimacy that avoids male
ejaculation near vaginal opening
Can be primary or temporary means of
preventing pregnancy
Can also be used when its not advisable to
have intercourse for other reasons, such as
after childbirth or abortion
No undesirable contraceptive side effects
Does not eliminate chances of spreading STDs,
especially if it involves oral or anal sex

Hormone-based contraceptives
5 types
1)
2)
3)
4)
5)

Oral contraceptives (pills)

Vaginal ring
Transdermal patch
Injected hormones
Hormonal IUDs

Gonadotropin releasing
hormone (GnRH)
triggers release of
gonadotropins FSH & LH

How hormonal
contraceptives
work

FSH & LH trigger

ovulation

Estrogen & progesterone in

hormonal contraceptives
inhibit LH, FSH, and GnRH
secretion, preventing ovulation

Progesterone also:
thickens cervical mucus to prevent
Passage of sperm into the uterus
changes uterine lining to inhibit implantation

Types of oral contraceptives

Constant-dose combination pill
Contains both estrogen and progestin
Dose of each is constant throughout cycle
Amount of estrogen in pills has decreased from approx. 175
micrograms in 1960 to avg. of 25 micrograms today

Triphasic pill
Levels of hormones (estrogen & progestin) fluctuate during
cycle

Seasonale
Reduces the # of menstrual periods to 4 instead of 13 per year
Has lower dose of estrogen and progestin

Progestin-only pill
Low dose of progestin and no estrogen
For women who should not take estrogen (breastfeeding, high
b.p., at risk for blood clots, smoke)

How to use oral contraceptives

Different types of OCs will differ in how to
begin, and other instructions--read instructions
carefully & talk w/health care practitioner
Dont skip pills, regardless of whether or not
you are having sex
Take pill at the same time each day
If you miss 1 pill: take missed pill as soon as you
remember, and then take next pill at the regular
time
If you miss >1 pill: consult health care practitioner
for advice; use a backup method for remainder of
your cycle

Oral contraceptives
possible side effects & health issues
Women who should not take OCs:
history of blood clots, strokes, heart/circulation
problems, jaundice, breast or uterine cancer, liver
disease

Women considered risky for taking OCs:

Women who smoke, have migraines, depression,
high b.p., epilepsy, diabetes/prediabetes, asthma,
varicose veins

Side effects of OCs can include:

Weight gain, decreased sexual interest,
headaches, mood changes, nausea, bleeding
between periods
May clear up after 2-3 cycles on the pill

Oral contraceptives
possible side effects & health issues
Rare but serious side effects of OCs--must be
reported to a health care practioner ASAP

10.3

Other hormonal methods

(contain both estrogen and progestin)

Vaginal ring (Nuvaring)
2 ring inserted into the vagina during
period
Worn for 3 weeks, removed for 1 week,
then replaced with new ring
Cost per year: $580
Pros: no daily pill; spontaneity
Cons: no STD protection, not effective for
women over 198 lbs.

Transdermal patch (Ortho Evra)

Patch is placed on buttock, abdomen,
outer upper arm, or upper torso
Replaced weekly for 3 weeks, then a
patch-free week
Cost per year: $420
Pros: no daily pill; spontaneity
Cons: no STD protection, skin irritation

Other hormonal methods

Injected Contraceptives

Depo-Provera (prog.); Lunelle (prog.+est.)

Injections: D-P every 12 weeks; Lunelle monthly
Cost per year: $196 for D-P; $420 for Lunelle
Pros: no daily pill; spontaneity
Cons: no STD protection, weight gain,
bleeding, mood change, frequent clinic visits
D-P: takes up to 10 months for a woman
to get pregnant after stopping injections

Contraceptive Implants

1.5 rod is inserted under skin of upper arm

Progestin-only
Effective for up to 3 years
Cost not yet known
Pros: no daily pill; spontaneity
Cons: no STD protection, weight gain,
bleeding, mood change, surgical procedure

(cont.)

Barrier & spermicide methods

Include:
Condoms (male & female)
Spermicides (foam, sponge)
Cervical barriers (diaphragm & cervical
cap)

Work by preventing sperm from

reaching an egg
Only condoms provide protection
against STIs

Condoms

(male)

Sheath that fits over the erect penis

The only temporary method of birth
control for men
Only form of contraception that
effectively reduces STI transmission
Made of thin latex, polyurethane, or natural membrane
Natural membrane (from sheep intestines) condoms can permit
passage of viruses, incl. those that cause AIDS, herpes, hepatitis, HPV

Many varieties
Different features, shapes, textures, colors, flavors
Some extended pleasure types have a desensitizing agent on the
inside to delay ejaculation
Lubricated or nonlubricated

Note: average shelf life of condoms is 5 years; dont store

latex condoms in hot places (glove compartment, back pocket) b/c
heat can deteriorate the latex

How to use the

(male)

condom

Pinch reservoir tip or twist tip of nonreservoir tip condom

before unrolling condom over the penis to leave room for
ejaculate--reduces chance of condom breaking
Unroll condom over erect penis before any contact between
the penis and vulva occurs
Common error: putting on a condom after vaginal penetration
but before ejaculation--increases risk of pregnancy & STI
transmission

Use a water-based lubricant to reduce risk of condom

breaking (oil-based lubricants deteriorate condom)
Hold condom at the base of the penis before withdrawing
from the vagina to avoid spilling semen inside vagina

Female condom
Consists of two flexible polyurethane rings
and a soft, loose-fitting polyurethane sheath
One ring at closed end fits loosely against cervix;
other ring at open end encircles the labial area

Can be inserted before sexual activity; dont

need to remove it immediately following
ejaculation

Costs, pros, & cons of condoms

Costs
Male condoms, about $0.75-$1 each
Female condoms, about $3 each

Advantages
STI protection!
Available w/o prescription or medical intervention

Disadvantages
Can reduce sensation
Polyurethane transmits heat well, so some say that the female
condom has less reduction in sensation

Interruption of sexual experience (though some couples

find sensual ways of incorporating condoms into foreplay)
Note: female condom can be inserted several hours before
intercourse

Vaginal spermicides
Include: foam, sponge, suppositories,
creams, film

Spermicide: chemical that kills sperm

(nonoxynol-9)
Cost: $0.85 per application

Advantage: no prescription necessary

Disadvantages:
Interruption of sexual experience (except
for the sponge)
Skin irritation (which can increase
susceptibility to STI infection)
No protection from STIs
Not effective enough to be used w/o a
condom or other method

Cervical barrier devices

Covering the cervix is one
of the oldest methods in
contraceptive history
Casanova (18th century Europe)
promoted using squeezed-out
lemon half; European women
shaped beeswax to cover cervix

diaphragm

FemCap

Cerv cap

Leas shield

Cervical cap: covers cervix only

Diaphragm: covers upper
vaginal wall behind cervix underneath pubic bone
FemCap & Leas shield have removal straps
Leas Shield allows a one-way flow of fluid from
cervix to vagina
Method is usually combined w/spermicide

How to use cervical barrier devices

Diaphragm & cervical cap: need to be fitted (may need to be
refitted w/weight gain or loss >10 lbs.)
FemCap & Leas Shield do not have to be fitted, but still
require a prescription in the U.S.
Use diaphragm & cervical cap only with water-based
lubricants b/c they are latex (FemCap & L.S. are silicone)
Can insert up to 6-8 hr. before intercourse; should leave in at
least 8 hr after

Placement of cervical barrier devices

(&FemCap)

Intrauterine Devices (IUDs)

Small plastic objects
inserted into uterus
2 types
Hormone-releasing
(progesterone)
Copper-releasing

progesterone

Have fine plastic

threads attached that
hang slightly out of cervix into vagina for removal
Very high continuation rate (how many women
are still using it one year after starting) compared
w/other methods

IUD Mechanisms of Action

Levonorgestrel-Releasing
IUD
(LNG-IUS, Mirena)

Inhibits fertilization
Thickens cervical mucous
Inhibits sperm function
Thins and suppresses the
endometrium

Copper-Releasing IUD
(ParaGard T380A)

Inhibits fertilization
Releases copper ions (Cu2+)
that reduce sperm motility
May disrupt the normal
division of oocytes and the
formation of fertilizable ova

Jonsson B, et al. Contraception. 1991;43:447-458; Videla-Rivero L, et al. Contraception.

1987;36:217-226; Kulier R, et al. Cochrane Database Syst Rev. 2006;3: CD005347.

Costs, pros, & cons of IUDs

Costs
Copper: $550 (good for up to 10 years)
Hormone: $500-$700 (good for up to 5 years)

Advantages

Very effective (essentially no user error)

Long-term protection
No interruption of sexual activity
Dont have to remember to use
Can be used during breast-feeding

Disadvantages
No STI protection
Risk of PID (usually within first 1-2 months following
insertion)

Rare incidence of perforating uterine wall

Emergency Contraception
Works mainly by preventing ovulation or fertilization
In theory, can also interfere w/implantation
Evidence suggests this is not primary mechanism of action
If it was, efficacy should not decrease w/short-term delay, as
long as EC was administered some time before implantation
However, EC is increasingly less effective w/delay

Oral contraceptive pills

95% effective within 24 hrs; 75% effective within 72 hrs

Preven: 2 doses of combined estrogen & progesterone
Plan B: 2 doses of progesterone
Other combinations of oral contraceptives can substitute
for these (see Table 10.7, p. 283)

Copper-T IUD
99% effective if inserted within 5 days

Fertility Awareness Methods

Standard days method
For women w/cycles btwn 26 & 32 days
Couples avoid unprotected intercourse btwn days 8-19 of each
menstrual cycle
Highest rate of effectiveness of natural family planning
methods

Mucus method: based on cyclical changes

Vaginal secretions change throughout cycle; woman learns to
read these changes and keeps a daily chart

Calendar method: self- knowledge of fertility

After charting cycles for some time (preferably 1 year), a
woman estimates the time she is ovulating based on the
calendar

Basal body-temperature
Based on changes in body temperature around ovulation

Often, some combination of these methods will be used

Standard Days Method

1 On the day you start your

your period, move the
ring to the RED bead.

If you have not started

your period by the day
after you put the ring on
the last brown bread,
contact your provider.

If you start
your period
before you put
the ring on the
darker brown
bead, contact
your provider.
(may not be a good
method for you)

On BROWN bead
days
you can
have intercourse
with very low
probability of
pregnancy.

(w/Cyclebeads)

Also, mark this date

on your calendar
2 Every morning
move the ring
to the next
bead.
On WHITE bead days
you can get pregnant.

Always move
the ring from
the narrow to
the wide end.

Avoid unprotected
intercourse to prevent
a pregnancy.

Arevalo M et al., Contraception, 2002;65:333-338.

When you start your

next period, move the
ring directly to red
bead and begin again.

Cervical Mucus Method

no unprotected
intercourse

Early
Mucus

Transitional
Mucus

Highly Fertile
Mucus

Slight amount
Thick
White
Sticky
Holds its shape

Increasing
amounts
Thinner
Cloudy
Slightly stretchy

Profuse
Thin
Transparent
Stretchy

Stanford JB, et al. Obstet Gynecol. 2003;101:1285-1293.

Calendar or Rhythm Method

28

3
4

23

24

25

26

27

21

22

Low-risk Days

19

10

20

11

18

17

Egg may still

be present

16

15

14

13

12

Ovulation

Billings JJ. Med J Aust. 1978;2:436.

Byer/Shainberg/Galliano. Dimensions of Human Sexuality,
5e. 1999, The McGraw-Hill Companies, Inc.

These days may be

unsafe if 28-day cycle
varies as much as 8-9
days between shortest
and longest cycles.

Intercourse on these days

may leave live sperm to
fertilize egg.

Basal Body Temperature Method

BBT=body temp in resting state on waking
Slight drop immediately before ovulation
After ovulation, release of progesterone
causes slight increase in temperature

Fertility Awareness Methods

pros & cons

Pros:

Essentially free
No medical side effects
Does not interrupt sexual activity
Woman gains awareness about her body and
natural cycles, which can increase comfort
w/sexuality
Acceptable to Catholic Church

Cons:
No STI protection
Requires some degree of discipline in order to keep
track of calendar/charts, etc.
Need to abstain from intercourse or use a backup
method during fertile days

Sterilization
Essentially permanent, although vasectomies are
sometimes reversible
Does not affect hormones, desire, sexual functioning
Female sterilization
Tubal sterilization: fallopian tubes are severed to block
passage of sperm & eggs
Transcervical sterilization: tiny coil inserted through cervix
into fallopian tubes
Coil promotes tissue growth that, after 3 months, blocks fallopian
tubes

Male sterilization (vasectomy)

Safer, less expensive, fewer complications than female
sterilization
Cutting and closing vas deferens (ducts that carry sperm)

Ex. of female sterilization procedure

Laparoscope: narrow, lighted viewing instrument that

is inserted into abdomen to locate the fallopian tubes

Ex. of male sterilization procedure

Vas deferens on
each side is cut;
small section is
removed, and the
ends are tied off
or cauterized

Less than Effective Methods

Nursing
amenorrhea is common for a brief period after
birth while breastfeeding
80% of women ovulate before first period (and so
do not know that they are fertile)

Withdrawal before ejaculation

difficult to judge when to withdraw

anxiety may lower pleasure for both partners
Cowper's gland fluid may carry sperm
any sperm on vulva may travel into vagina/uterus

Douching
sperm reach uterus in 1-2 minutes
douching may speed sperm along
irritates vaginal tissue

New Directions in Contraception

for men
The male pill: Testosterone &
progestin may lower sperm count
New forms of reversible vasectomy
Injection of a blocking gel into vas
deferens; gel is dissolved to reverse the
procedure
Insertion of two plugs into each vas
deferens--can be removed later

New Directions in Contraception for

women
Most new developments are
improvements on existing
contraception for females
Variations on methods of delivery,
formulation of hormones
New designs of IUDs, female condoms
spermicides with microbicides (to kill
microbes that cause STIs)

Discussion question:
Should women convicted of child
abuse be mandated to use doctorcertified contraception (e.g.
injected/implanted hormonal
contraceptive, or IUD)?