Contraception

Shelley Mitchell

Issues
Decision made by individual or by couple
Many factors influence decision:

Advantages & disadvantages of various methods

Side effects & contraindications
Effectiveness
Perfect use vs. typical use

Expense
Spiritual/cultural beliefs
Practicality of method

Some facts

Correct & consistent use of contraceptives results in lower risk of

pregnancy
Using more than one method together dramatically lowers risk of
pregnancy
Emergency contraception offers last chance to prevent pregnancy
after unprotected intercourse or when extent of protection isnt
clear
Most contraceptives pose little risk to most users health
Half of all pregnancies are unintended (3.1 million/yr)
More than 4/10 unintended pregnancies end in elective abortion
Half of unintended pregnancies result from contraceptive failure
1/3 of all births are unintended

Source: Contraceptive Technology (19th ed)

Basic types of
contraception

Fertility awareness methods

Barrier methods
Situational methods
Spermicides
IUDs
Hormonal contraception
Operative sterilization

Fertility Awareness Methods

Also known as Natural Family Planning
Based on understanding ovulatory cycle
Require periods of abstinence & careful recording of events
throughout cycle
Cooperation very important
Free, safe, and acceptable to all spiritual beliefs
Require extensive initial counseling
25% of women will experience unintended pregnancy in first
year (typical use; 3-5% in perfect use)
Some women combine with barrier methods (use during fertile
periods) and/or combine types of FAM
More difficult when breastfeeding (masks some signs)

Fertility Awareness Methods

Basal body temperature (BBT)

Woman takes temp q morning

Must be before any activity
Uses BBT thermometer and same method
Chart for 3-4 months to determine normal pattern
Temp sometimes drops just before ovulation
Almost always rises & remains elevated for several
days after
Abstain from intercourse several days before and
3 days after anticipated ovulation

Fertility Awareness Methods

Calendar method

Also known as rhythm method

Assumes ovulation takes place 14 days before
start of menstrual period
Sperm viable for 48-72 hours, ovum for 24 hours
Record menstrual cycles for 6-8 months to
determine shortest & longest cycles
Use record to identify fertile & infertile periods
Least reliable of FAM

Fertility Awareness Methods

Cervical mucus method

Also known as Billings or ovulation method

Involves careful assessment of cervical mucus changes throughout
cycle
Ovulation mucus clearer, more stretchable (spinnbarkeit), more
permeable to sperm
Also ferns when dried on glass slide
Luteal phase mucus thick, sticky, traps sperm (progesterone
influence)
Woman abstains from intercourse for one cycle & assesses mucus q
D
Peak day of wetness & clear, stretchable mucus is assumed day of
ovulation
Can be used by women with irregular cycles

Fertility Awareness Methods

Symptothermal method

Multiple assessments made & recorded

Cycle days, coitus, cervical mucus
changes, BBT, & secondary changes
(increased libido, bloating, mittelschmerz)
Combined approach is more effective

Situational contraceptives
Abstinence
Coitus interruptus (withdrawal)

Very unreliable
Demands great self-control
Pre-ejaculate may contain sperm, esp. after a recent ejaculation

Douching after intercourse

Not recommended; may facilitate conception

Lactational amenorrhea method (LAM)

Lactation depresses ovarian function

Exclusive breastfeeding, from the breast (no pumping), in first six
months following birth without PP menses is 98% effective
Even more effective if used with other method of contracep.

Barrier Methods

Male condom
Female condom
Diaphragm
Cervical cap
Vaginal sponge
Usually used with spermicides
All vaginal barriers may cause increased risk of
toxic shock syndrome if used longer than
recommended

Spermicides
Available as creams, jellies, foams, film,
suppositories
May require up to 30 minutes to become
effective
Minimally effective if used alone
May cause skin/mucus membrane
irritation, allergic reaction

Barrier methods
Male condom

Must be used correctly to be effective

No side effects
Inexpensive and easily available
Usually latex, but other types available for allergic
Offers protection from pregnancy and STIs
May also be used for STI protection in oral and
anal intercourse

Barrier Methods
Female condoms

Thin sheath with flexible ring at each end

May be inserted up to 8 hrs before intercourse
Internal ring functions like diaphragm to cover cervix
External ring covers portion of perineum
Cannot be used with male condom
Slightly less reliable than other barrier methods
More expensive than male condom
Noisy and cumbersome
Available OTC

Barrier methods
Diaphragm

Must be used with spermicide

Requires prescription and fitting by HCP
Fits over cervix between pubic symphysis and posterior
fornix
Must be inserted before and remain in place at least six
hours after intercourse; additional spermicide must be
inserted for additional acts of coitus
No hormones involved; may help protect cervix against HPV
Requires comfort with insertion and checking placement
Not recommended for those with hx of recurrent UTI

Barrier methods
Cervical cap

Fits over cervix by suction (smaller than

diaphragm)
Also used with spermicide
May be left in place 24- 48 hrs
May be more difficult to fit than diaphragm
Requires more dexterity/comfort with body
to place correctly

Barrier methods
Leas shield

Similar to cervical cap, but with valve for passage

of secretions & air
One size fits all, but only available by rx in US

Contraceptive sponge

Available OTC, one size (expensive)

Contains nonoxynol-9
No additional spermicide needed for additional
coitus within 24 hrs sponge may be in place
Less effective in parous women

Intrauterine contraception
Two forms available in US

Paragard (copper T)
Mirena (releases levonogestrel)

Trigger spermicidal reaction in body, preventing

fertilization
Provide long-term, highly effective contraception
Risks include PID, perforation, dysmenorrhea,
expulsion
Also may be used as emergency contraception
(Paragard only)

Intrauterine contraception
Marketed in US to parous women in stable, long-term,
monogamous relationships
Inserted into uterus by physician, NP, or CNM
Nursing action: premedicate with ibuprofen to decrease
cramping with procedure
Usually inserted either during menses or during first six weeks
postpartum (may be inserted any time as long as not pregnant)
String protrudes through cervix into vagina (path for ascending
infection if exposed to STI)
Women should check string after each menses
Warning signs: late period, abnormal bleeding (may happen
with Mirena), abnormal discharge, s/sx of infection

Intrauterine contraception
Paragard

Works by impairing fertilization

May stay in place up to ten years
May cause increased bleeding/cramping with
periods
No hormones
Contraindicated in copper allergy
Low daily cost
High user compliance, continuation, & satisfaction
May help prevent endometrial cancer

Intrauterine contraception
Mirena

Releases small amount of progesterone (10% of oral

contraceptives)
May remain in place for up to 5 yrs
Decreased bleeding, cramping compared to
Paragard

May be recommended to women with menorrhagia

Some women stop ovulating while its in place
May cease bleeding altogether
May have irregular bleeding, esp. in first few months

Increased risk of ovarian cysts

Hormonal contraception

Combined oral contraceptives

Progesterone-only oral contraceptives
Implanted contraceptives
Injected contraceptives
Other hormonal contraceptives
Vaginal ring
Contraceptive patch

Hormonal contraception
Combined oral contraceptives (COCs)

Birth control pills with both estrogen & progesterone

Most taken daily for 21 days, with 7 days of placebo
or no pill (exceptions: Seasonale,Seasonique, Yaz)
Many formulations--monophasic, multiphasic,
different strengths, different progesterones
Side effects differ somewhat based on formulation-see p. 82
Very effective if used correctly
No protection against STI

Hormonal contraception
COCs

Action:

Suppress ovulation through negative feedback

to hypothalamic-pituitary axis
Thickening of cervical mucus to prevent sperm
entry
May also slow tubal motility, disrupt transport of
ova, change function of endometrial vessels,
cause endometrial atrophy, and inhibit
implantation (not proven)

Hormonal contraception
COCs

Contraindications

Pregnancy
Hx of thrombophlebitis/thromboembolic disease
Acute or chronic liver disease or gallbladder disease
Estrogen-depended carcinoma
Undiagnosed menorrhagia
Smoking (esp. if over 35)
Diabetes
HTN
Hyperlipidemia

Hormonal contraception
COCs

Caution/relative contraindications

Hx of migraine headaches
Seizure disorder
Depression
Oligomenorrhea
Amenorrhea
Often safer than pregnancy

Hormonal contraception
COCs

Noncontraceptive benefits:

Decreased risk of ovarian and endometrial cancer

Relief of menstrual symptoms (e.g. fewer/less painful cramps,
lighter flow)
Regulation of irregular menses
Reduced risk of ovarian cysts
Improvement in menstrual migraines
Decreased incidence of ectopic pregnancy
Decreased incidence of benign breast disease & iron deficiency
anemia
Some pills decrease PMS/PMDD symptoms (Yasmin & Yaz)
Reduced symptoms of endometriosis, acne, hirsutism

Hormonal contraception
Other combined methods

NuvaRing vaginal ring (must be comfortable inserting)

Ortho Evra contraceptive patch
Similar effectiveness, non-contraceptive benefits,
contraindications, and side effects as COCs
Patch dispenses higher dose of hormones than COCs, with
possible higher risk of venous thromboemobolic conditions
Ring uses progesterone formulation that may increase risk of
VTC as well
Neither require daily use
Patch replaced weekly for three weeks, then one week without
Ring left in for three weeks, then one week without

Hormonal contraception
Progesterone only pills (mini-pill)

Do not suppress ovulation

Do not affect breast milk supply (good for nursing
moms)
Must be taken at same time every day to be
effective
Often causes irregular bleeding
Not as effective as combined methods
No risk of venous thromboembolic events

Hormonal contraception
Injectable contraception

Combined injection (Lunelle) no longer available in

US
Other formulations use progesterone only
Depo-Provera (DMPA-IM 150 mg/1 ml) most
commonly used
Given IM q 12 weeks

Depo-subQ provera 104 (DMPA-SC 104 mg/0.65

ml) new formulation
Given SC q 12 weeks

Hormonal contraception
DMPA actions & advantages

Works by inhibiting ovulation (suppresses FSH &

LH), thickening cervical mucus
Safe for those who cant take estrogen (e.g. hx of
DVT)
Highly effective
Very light to no menstrual periods (but can have
irregular bleeding)
New SC formulation less painful, may be selfadministered

Hormonal contraception
DMPA disadvantages

Most women have irregular bleeding/spotting

Most women gain weight
May increase risk of depression
May decrease bone density
May take up to one year to reverse effects/regain
fertility
Must return q 3 mos for injections
No protection from STI

Hormonal contraception
Implanted contraception

Norplant no longer available in US

Implanon

Single rod implanted under skin of upper arm

Provides contraception for 3 years
Releases progestin continuously
Extremely effective
Like all progestin-only methods, causes irregular
bleeding in many women
Must be inserted by HCP & removed later

Emergency contraception
Used after unprotected sex, contraceptive failure, or
unsure protection
Should be taken as soon as possible after incident
No medical contraindications except established
pregnancy
Most effective in first 72 hours, but still somewhat
effective up to 5 days after coitus
Providing EC is the standard of care for women who
request it

Emergency contraception
Methods

Combined hormonal (Preven, with estrogen & progestin,

withdrawn from US market in 2004)
Progestin-only (Plan B, available OTC for those >/= 18, rx for
those <18, more effective & better tolerated than Preven)
May use ordinary COCs or minipills to make up dose
comparable to Preven or Plan B
Copper IUD insertion (99% effective; can insert up to 7 days
after coitus)
Not the same as abortion pill (RU486/mifepristone)!

Operative sterilization
Surgical procedures that permanently
prevent pregnancy
Very difficult to reverse
Vasectomy and tubal ligation
Extremely effective and cost-effective
Does not protect against STI

Operative sterilization
Vasectomy

Relatively minor procedure (safer and less expensive

than female sterilization)
Surgical severing of vas deferens
Takes 4-6 weeks/6-36 ejaculations to clear remaining
active sperm from vas
Couple needs to use alternate method and bring in
semen samples to verify (and recheck at 6-12
months)
SE include pain, infection, hematoma, sperm
granulomas, spontaneous reanastomosis

Operative sterilization
Female sterilization

May be done with repeat cesarean section or

postpartum from vaginal birth
More serious surgery than vasectomy
Complications include coagulation burns to bowel,
bowel perforation, pain, infection, hemorrhage,
adverse effects of anesthesia
New transcervical method (Essure) does not
require opening abdominal cavity, can be done
under local anesthesia in physicians office