Chap 24: Contraception and Sterilization
The same primary side effects and noncontraceptive health benefits of OCPs apply to the patch as well.
-can cause skin irritation in some users. -self-administered only once a week.
Emergency Copper T IUD insertion reduces the risk of preg- nancy by
99.8%; therefore, only 1 in 1,000 become pregnant after emergency IUD insertion, making it the most effective form of emergency contraception.
lactational amenorrhea: Continuation of nursing has long been a widespread method of contraception for many couples.
After delivery, the restoration of ovulation is delayed because of a nursing-induced hypothalamic suppression of ovulation. Specifically, there is a prolactin-induced inhibition of pulsatile gonadotrophin- releasing hormone (GnRH) from the hypothalamus resulting in suppression of ovulation.
The ring is placed in the vagina for 3 weeks (it is likely effective for 4 weeks), and is removed for 1 week to allow for a withdrawal bleed.
Again, this hormone-free period can be skipped to allow for continuous dosing, typically for 3 months.
Injectable Progesterone-Only Contraception—Depo-Provera
Although it was only approved for contraceptive use in the United States in 1992, Depo-Provera (medroxyprogesterone acetate; DMPA) has been used in other countries since the mid-1960s.
The rate of surgical sterilization as a method of contracep- tion has increased dramatically over the past three decades.
Approximately 30% of reproductive-age couples in the United States and Great Britain choose female sterilization for contraceptive purposes. A similar number of men seek vasectomies each year.
In most of these women, symptoms are due to discontinuation of hormone-containing contraceptives.
As a result, patients may experience heavier baseline menses and dysmenorrhea. In rare circumstances, malplacement of Essure coils has contributed to significant pain requiring subsequent surgical removal.
Medications That Reduce the Efficacy of Oral Contraceptives
Barbiturates Carbamazepine (Tegretol) Griseofulvin Phenytoin (Dilantin) Rifampin St. John's wort Topiramate (Topamax)
The Effects of Depo-Provera Use on Bone Mineralization
Bone density is decreased in women using Depo-Provera, due to the decrease in ovarian estradiol production The decrease in bone density is most rapid in the first year of use The decrease in bone density increases with length of use The decrease in bone density is reversible and occurs over 6 mo to 2y There is no role for the use of bone density screening (DEXA) in DMPA users There is no role for the use of bisphosphonates, estrogens, and SERMS in DMPA users Women on Depo-Provera should be encouraged to take calcium and vitamin D, stop smoking, and do regular weight-bearing exercises. DMPA, Depo medroxyprogesterone acetate; SERMs, selective estrogen receptor modulator.
Complications Associated with Oral Contraceptives
Cardiovascular Deep Vein Thrombosis (DVT) Pulmonary Embolus (PE) Cerebrovascular Accident (CVA) Myocardial Infarction (MI) Hypertension Other Cholelithiasis Cholecystitis Benign liver adenomas (rare) Cervical adenocarcinoma (rare) Retinal thrombosis (rare)
Medications Whose Efficacies Are Changed by Oral Contraceptives
Chlordiazepoxide (Librium) Diazepam (Valium) Hypoglycemics Methyldopa Phenothiazines Theophylline Tricyclic antidepressants
Advantages of condoms
Condoms are widely available for a moderate cost and carry the added benefit of preventing the transmission of many sexually transmitted infections (STIs). Condoms are the only method of contraception that offers protection against human immunodeficiency virus (HIV).
Although extremely safe, uncommon side effects and compli- cations of IUDs can be potentially severe and dangerous. These include pain and bleeding, pregnancy, expulsion, perforation, and infection
Contraindications for Intrauterine Device (IUD) Use Absolute contraindications Known or suspected pregnancy Undiagnosed abnormal vaginal bleeding Acute cervical, uterine, or salpingeal infection Copper allergy or Wilson disease (for ParaGard only) Current breast cancer (for Mirena only) Relative contraindications Prior ectopic pregnancy History of STIs in past 3 months Uterine anomaly or fibroid distorting the cavity Current menorrhagia or dysmenorrhea (for ParaGard only) STI, sexually transmitted infection.
Noncontraceptive Health Benefits of Oral Contraceptives
Decrease risk of serious diseases Ovarian cancer Endometrial cancer Ectopic pregnancy (combination pills only) Severe anemia Pelvic inflammatory disease Salpingitis Improve quality-of-life problems Iron deficiency anemia Dysmenorrhea Functional ovarian cysts Benign breast disease Osteoporosis (increased bone density) Rheumatoid arthritis Treat/manage many disorders Dysfunctional uterine bleeding Control of bleeding in bleeding disorders and anovulation Dysmenorrhea Endometriosis Acne/hirsutism Premenstrual syndrome
Several medications are thought to interact with oral contra- ceptives resulting in reduced effectiveness of the pill.
Despite common belief, the only antibiotic which lowers the effective of OCPs is Rifampin. Conversely, oral contraceptives can also reduce the efficacy of many medications
It is available in three forms:
ECPs (also called the postcoital or the morning-after pill), an emergently inserted Copper T IUD (ParaGard), or a selective progesterone recep- tor modulator (ulipristal acetate or Ella).
More recently, titanium Filshie clips have been used for tubal ligation, but long-term efficacy rates are not yet available.
Essure offers the lowest rates of all of these methods when tubal occlusion is achieved (2.6/1,000 pregnancy rate over 5 years, aside from unipolar sterilization, which is no longer used).
The effectiveness of lactational amenorrhea as a method of contraception can be enhanced by following certain principles.
First, breastfeeding should be the only form of nutrition for the infant. Second, this method of contraception should be used only as long as the woman is experiencing amenorrhea and, even then, it should only be used for a maximum of 6 months after delivery.
make the user more susceptible to STIs including HIV by causing vaginal irritation. For this reason, spermicides should not be used by women with HIV or at high risk of contracting HIV.
For the general public, it is strongly recommended that consistent condom use be em- ployed whenever protection against STIs is desired.
The pregnancy rate with IUD use is very low; however, when pregnancy does occur, the spontaneous abortion rate is increased to 40% to 50% for women who become pregnant with an IUD in place
Given this, if intrauterine pregnancy oc- curs while an IUD is in place, the device should be removed by gentle traction on the string. The risk of life-threatening spon- taneous septic abortion has only been seen with the Dalkon shield, which is no longer available. The IUD is not associated with any increased risk of congenital abnormalities
The advent of new progestins and lower estrogen doses has led to pill formulations that are es- sentially neutral in terms of cardiovascular effect.
However, combination oral contraceptive use is still contraindicated in women over age 35 years who smoke. These women often benefit from progesterone-only IUDs or permanent female or male sterilization.
Periodic abstinence uses neither chemical nor mechanical barriers to conception and is therefore the method of choice for many couples for philosophical, medical, and/or religious reasons.
However, this method requires a highly motivated couple willing to learn reproductive physiology, predict ovulation, and abstain from intercourse
Tubal ligation results in a very low risk of pregnancy.
However, when pregnancy does occur, there is an increased risk of ectopic pregnancy (1 in 15,000). However, nearly 1,000 maternal lives are saved due to sterilization during the period from the time of sterilization to the end of the woman's reproductive life. The rates of ectopic pregnancy after Essure is decreased compared to tubal ligation Patients may also benefit from a reduction in the risk of ovarian cancer
Intrauterine devices are introduced into the endometrial cavity using a cervical cannula
IUDs have two monofilament strings that extend through the cervix where they can be checked to detect expulsion or migration (Fig. 24-8). The strings also facilitate removal of the device by the clinician.
ECPs are extremely effective in preventing pregnancy and are safe for the user
In 2006, the FDA approved over-the-counter dispensing of Plan B emergency contraception without a pre- scription for men and women aged 17 years and older.
The duration of ovulatory suppression during nursing is highly variable.
In fact, 50% of lactating mothers will begin to ovulate between 6 and 12 months after delivery, even while breastfeeding. Importantly, return of ovulation occurs before the return of menstruation. As a result, 15% to 55% of mothers using lactation for contraception subsequently become pregnant.
Emergency contraception works by preventing pregnancy, not by disrupting an implanted pregnancy.
In fact, ECP is thought to account for a 40% decline in therapeutic abortions in the past 10 years while also decreasing the number of teen pregnancies.
The failure rate for vasectomy in actual practice is 0.15%.
In fact, with the exception of Essure, vasectomy is safer, simpler, and more effective than female sterilization.
In general, because IUDs are so effective at preventing pregnancy, the risk of ectopic pregnancy is reduced in IUD users compared to that of noncontraceptive users.
In the rare event that a woman does become pregnant with an IUD in place, however, the risk of ectopic pregnancy may be as high as 30% to 50% of those patients. Although controversial, the IUD is an acceptable form of contraception for women with a prior history of ectopic pregnancy.
Antibiotic prophylaxis is not needed for IUD inser- tion nor is it indicated for bacterial endocarditis prophylaxis.
Instead, emphasis should be placed on appropriate patient selection and screening women for gonorrhea and Chlamydia prior to insertion of the IUD. Moreover, studies now show that women using the Mirena IUD have a decreased risk of PID due to the protection of progesterone-induced cervical mucus thickening. Given these findings, Mirena IUDs are being used more liberally in younger women, women who have not com- pleted childbearing, and nulliparous women.
major side effect of Nexplanon
Irregular and unpredictable light bleeding In the majority of cases (75%), the bleeding is lighter than a normal menstrual bleed and requires only a panty liner or less for protection. However, irregular bleeding was the reason for approximately 15% of discontinuations, followed by headaches (approximately 12%).
Over 70% of patients experience spotting and irregular menses during the first year of use.
Irregular bleeding is the primary reason for discontinuing Depo-Provera
major disadvantages of DMPA
Irregular bleeding to DMPA use, weight gain, and mood changes
The Mirena IUD has been found to decrease menorrhagia (90% less blood loss) and dysmenorrhea.
It is also as effective as oral progestins in treating endometriosis, endometrial hy- perplasia, and cancer. It also protects the user from PID. As a result, this decreases the number of surgeries needed for pain and bleeding (hysterectomies, D&Cs, endometrial ablations). About 20% of women will experience amenorrhea while using a Mirena IUD for 1 year and 60% will experience amenorrhea after using the Mirena for 5 years.
A closely related drug to ulipristal is mifepristone
Its mechanism of action is similar to ulipristal. Cur- rently, mifepristone is not available in the United States for prevention of pregnancy, although trials have shown 99% to 100% efficacy (similar to or better than that of current ECPs). its current use in the United States is limited to medical termination of pregnancy.
Ulipristal (Ella, EllaOne) is a derivative of 19-norprogesterone, and acts as a selective progesterone re- ceptor modulator (SPRM) with agonist/antagonist effects at progesterone receptor sites.
Its primary mechanism of action is to delay ovulation (follicular rupture) and inhibit implanta- tion into the endometrial lining
A 365-day OCP regimen known as Lybrel was approved by the FDA.
Lybrel provides a combination estrogen and progestin pill each day, 365 days of the year. There is more breakthrough bleeding in this regimen, but no formal monthly or quarterly withdrawal bleed.
Female condoms protect against many STIs while also placing the control of contraception with the female partner.
Major drawbacks include cost and overall bulkiness. The acceptability rating is somewhat higher for the male partner (75% to 80%) than for the female partner (65% to 70%).
Implantable Progesterone-Only Contraception—Nexplanon
Nexplanon (the newest generation of the Implanon device) is a single-rod, subdermal progestin implant that provides 3 years of uninterrupted contraceptive coverage.
The patch has been shown to have a 1% pregnancy rate in actual use—similar to other combination hormonal methods.
Ortho Evra has been found to have a decreased effectiveness in markedly overweight women ( 198 lb or 90 kg).
Progestin-only pills (POPs; Micronor, Nor-QD) deliver a small daily dose of progestin (0.35 mg norethindrone) without any estrogen.
POPs have lower progestin doses than combina- tion pills, thus the nickname minipills
The theoretical effectiveness of the diaphragm approaches 94%. The actual effectiveness rate of the diaphragm with sper- micide is 80% to 85%.
Possible side effects include bladder irritation, which can lead to urinary tract infections (UTIs). If the diaphragm is left in place too long, colonization by Staphylococcus aureus may lead to the development of toxic shock syndrome (TSS). Some women also experience a hypersensitivity to the rubber, latex, or spermicide.
When appropriate timing of placement is utilized, Nexplanon is effective 24 hours after placement and has quick return to fertility once the device is removed by a clinician.
Similar to other contraceptives, it acts by suppressing ovulation, altering the endometrium, and increasing cervical mucous viscosity.
It is available worldwide and is administered in a single dose of 30 mg within 120 hours (5 days) after unprotected coital event.
Small trials suggest that ulipristal is more effective than progestin-only regimens in pre- venting pregnancy when used between the 72- and 120-hour postcoital time period.
There are no side effects associated with tubal sterilization.
Some women report pain and menstrual disturbances. This phenomenon was once described as posttubal ligation syndrome but has largely been discounted by the literature
The mechanism of action for IUDs is not completely un- derstood, but they are known to act mainly by killing sperm (spermicidal) and preventing fertilization.
Specifically, the primary method of action is to elicit a sterile inflammatory response resulting in sperm being engulfed, immobilized, and destroyed by inflammatory cells.
Spermicides can irritate the vaginal mucosa and external male and female genitalia.
Spermicidal agents are widely available in a variety of forms and are relatively inexpensive. Some formulations can also be messy to use.
spermicides should be placed in the vagina at least 30 minutes before intercourse to allow for dispersion throughout the vagina
Spermicides may be used alone but are far more effective when used in conjunction with condoms, cervical caps, diaphragms, or other contracep- tive methods.
Modern techniques have evolved to incorporate sterilization procedures in both operating room and outpatient (in-office) practices that involve nonincisional hysteroscopic approaches
The Essure was introduced in the United States in 2002. In this method, flexible form-fitting microinserts are introduced into the interstitial (uterine) portions of the fallopian tubes. An outer spring coil molds to the shape of the fallopian tube to anchor the microinsert. Over about 12 weeks, sterilization is accomplished as in-growth of tissue around the coils results in tissue barrier occlusion in the fal- lopian tubes.
ParaGard is also approved for emer- gency contraception when placed within 72 hours of unpro- tected intercourse or contraceptive failure
The ParaGard IUD can be inserted immediately postpartum (within 10 minutes of placental delivery) with an increased risk of expulsion but no increased risk of infection or perforation. Both the Mirena and ParaGard IUDs can be used safely at 6 weeks postpartum and are safe in breastfeeding women.
When properly used, the condom can be 98% effective in pre- venting conception
The actual efficacy rate in the population is 85% to 90%. To maximize effectiveness and decrease the risk of condom breakage, it is important to leave a well at the tip of the condom to collect the ejaculate and to avoid leakage of semen as the penis is withdrawn. Efficacy is also increased by use of spermicide-containing condoms or by using a spermi- cide along with condoms
Transdermal Estrogen and Progestin Hormonal Contraception—Ortho Evra
The contraceptive patch (Fig. 24-11) with the brand name Ortho Evra releases progestin and ethinyl estradiol. The patch releases 150 mg per day of the progestin, norelgestromin, and 20 mg per day of ethinyl estradiol.
Spermicidal jelly is placed on the rim and on either side of the diaphragm, and it is placed into the vagina so that it covers the cervix
The diaphragm and spermicide should be placed in the vagina before intercourse and left in place for 6 to 8 hours after intercourse If further intercourse is to take place within 6 to 8 hours after the first episode of intercourse, additional spermicide should be placed in the vagina without removing the diaphragm.
The diaphragm must be fitted and prescribed by a clinician, making its initial cost significantly higher than over-the-counter methods of contraception
The diaphragm should be replaced every 2 years or when the patient gains or loses more than 20% of her body weight. It should also be checked after each pregnancy. Women who are not comfortable with inserting the diaphragm, or who cannot be properly fitted due to pelvic relaxation defects are poor candidates for the diaphragm, as are women who are at high risk of HIV.
Because one size of vaginal ring fits all women, the vaginal ring need does not need to be fitted by a clinician. Women place the ring in the vagina themselves for 3 continuous weeks and then remove it for 1 week. Because the ring is left in place continuously, it provides a low, steady release of hormone with lower total hormone exposure compared to other combination hormone methods. And while douching with the NuvaRing in place is discouraged, the use of antifungal agents and spermi- cides is permitted.
The disadvantages of the vaginal ring include a woman's (or partner's) concern with having a foreign body in the vagina and the potential for expulsion. Studies have shown that women do not feel the ring inside once placed in the vagina and the ring does not need to be removed for intercourse. If it is re- moved for intercourse, it should be rinsed in cool to lukewarm water and replaced within 3 hours. Reasons for discontinuation include discomfort, headache, vaginal discharge, and recurrent vaginitis.
The efficacy for IUDs rivals that of permanent sterilization with prolonged use
The failure rate is 0.8% for the ParaGard and 0.2% for the Mirena IUD within the first year of use. The cumulative 10-year failure rate for the ParaGard is ap- proximately 1.9% and the cumulative 5-year failure rate for the Mirena is 0.7%. Some sources state that the failure rate in the first year is closer to 3%, partially due to unrecognized expulsions.
Tubal ligation offers the advantage of permanent effective contraception without continual expense, effort, or motivation.
The mortality rate of bilateral tubal ligation is 4 in 100,000 women.
Side effects of EPRM
The most common side effects are similar to ECPs and include self-limited headache, bleeding, nausea, and abdominal pain.
Tubal ligation can be performed immediately postpartum (postpartum sterilization [PPS]) through a small subumbilical incision using epidural or spinal anesthesia
The most commonly used method, is the modified Pomeroy tubal ligation (aka Park- land),
Spermicidal agents come in varying forms including vaginal creams, gels, films, suppositories, and foams
The most widely used spermicides are nonoxynol-9 and octoxynol-9. Nonoxynol-9 and octoxynol-9 both disrupt the cell membranes of the spermatozoa and also act as a mechanical barrier to the cervical canal.
Emergency progesterone receptor modulators
The newest form of ECP received FDA approval in August of 2010.
Before performing any sterilization procedure, careful counseling should be provided and informed consent obtained.
The patient should understand the permanent and largely ir- reversible nature of the procedure, operative risks, chance of failure, and possible side effects.
Newer formulations are now available that give 24 days of hormone (rather than the traditional 21 days) and a 4-day hormone-free interval.
The so-called 24/4 regimens (i.e., Yaz) result in a shorter 3- to 4-day menstrual cycle for most users. Pills that contain iron supplementation and even folic acid are also available.
When taken within 72 hours of intercourse, ECPs have a failure rate of 0.2% to 3%.
The sooner an ECP is taken after unprotected intercourse, the more effective it is.
Of women who undergo permanent sterilization, regret is highest in women who were under 30 years when the proce- dure was performed.
The success of reversal varies from 41% to 84% depending on the method used: clips (highest reversal success rate) bands pomeroy electrocauterization (lowest reversal success rate)
It is used only if a woman is not already pregnant from a previous act of intercourse.
The use of emergency con- traceptive pills (ECPs) is not indicated in women with a known or suspected pregnancy. However, there is no known evidence of harm to the patient, her pregnancy, or to the fetus if ECPs are unintentionally taken during pregnancy.
The IUD is also thought to reduce tubal motility that in turn inhibits sperm and blastocyst transport. IUDs do not affect ovulation, nor do they act as abortifacients.
Their presumed mechanisms of action are aug- mented by the addition of levonorgestrel in the Mirena IUD and copper in the ParaGard IUD Progesterone in the Mirena thickens the cervical mucus and atrophies the endometrium to prevent implantation. Copper in the ParaGard is thought to hamper sperm motility and capitation so sperm rarely reach the fallopian tube and are unable to fertilize the ovum.
The overall average estrogen concentration is higher in Ortho Evra users compared to women taking standard OCPs.
Therefore, these patients should be made aware of the increased risk of thromboembolism, specifically DVT and PE in Ortho Evra users compared to women taking standard OCPs. There does not appear to be an increased risk of heart attack and stroke in these patients.
Barrier methods and spermicides:
These contraceptive methods work by preventing sperm from entering the endometrial cavity, fallopian tubes, and peritoneal cavity.
Seasonale, Seasonique, and their generic equivalents contains 84 consecutive hormonal pills followed by 7 placebo pills, or 7 low-estrogen pills, respectively.
These dosing regimens were designed to decrease the number of withdrawal bleeds to four per year, again, with the goal of minimizing menstrual- related symptoms.
POPs are believed to thicken the cervical mucus making it less permeable to sperm
This effect, however, decreases after 22 hours so the minipill must be taken at the same time each day. Other mechanisms of action include endometrial atrophy and ovulation suppression (50% of cycles).
A newer low-dose DMPA (104 mg/0.65 mL, subcutaneous "SC") is also available although not widely used yet.
This formulation carries the benefit of lower progestin levels but the same efficacy rates.
Women apply one patch each week for 3 weeks followed by 1 week patch-free period during which they will have a withdrawal bleed.
This hormone-free period can be skipped to allow for continuous 3-month dosing. Again, just like combined OCPs, the primary mechanism of action is suppression of ovulation by decreasing endogenous FSH and LH levels
Placement of IUDs in women with cervical infections can lead to insertion-related pelvic inflammatory disease (PID).
This increased risk is now believed to be due to contamination of the endometrial cavity at the time of insertion. Otherwise, pelvic infection is rarely seen beyond the first 20 days after insertion.
Its use is also controversial given its potential use as an abortifactant (although not approved for this indication).
This is, in contrast to progestin-only or combined estrogen/progestin ECPs, because they do not terminate an existing pregnancy nor cause teratogenic effects. For these reasons, ulipristal is not as widely prescribed when compared with other ECPs.
Periodic abstinence is relatively unreliable compared to the more traditional methods of contraception.
This low reliability may require prolonged periods of abstinence and regular menstrual cycles, making it less desirable for some couples.
The most common prepackaged formulation is Plan B (progestin only).
This regimen can be taken as a single 1.5 mg of Levonorgestrel (Plan B One Step) or as two 0.75 mg doses taken 12 hours apart (Next Choice).
Absolute Contraindications to Combination Estrogen-Progesterone Contraceptives
Thromboembolism Pulmonary embolism Coronary artery disease Cerebrovascular accident Smokers over the age of 35 y Breast/endometrial cancer Unexplained vaginal bleeding Abnormal liver function Known or suspected pregnancy Severe hypercholesterolemia Severe hypertriglyceridemia
Women using DMPA for more than 2 years may experience a reversible decrease in bone mineralization similar to that seen in lactating women, due to the decrease in ovarian estradiol production.
Thus, calcium, vitamin D, weight-bearing exercises, and smoking cessation should be encouraged in all women using Depo-Provera. A recent randomized controlled trial demonstrated the SC and IM forms to be similar in their effects on bone mineral density.
With a first-year theoretical failure rate of only 0.3%, Depo-Provera is one of the most effective contraceptive methods available.
Typical use failure rates are estimated at 3%, mostly attributed to patients failing to return at scheduled times for follow-up injections
Relative Contraindications to Combination Estrogen-Progesterone Contraceptives
Uterine fibroids Lactation Diabetes mellitus Hepatic disease Hypertension Lupus (SLE) Age 40+ and high risk for vascular disease Migraine headaches Seizure disorders elective surgery
Vasectomy is a permanent, highly effective form of contracep- tion with few, if any, side effects
Vasectomy is generally safer and less expensive than tubal ligation and can be performed as an outpatient under local anesthesia. Vasectomy offers per- manent sterilization. The success rate of vasal reanastomosis is 60% to 70%. Pregnancy rates after vasectomy reversal range from 18% to 60%.
The success rate of reanastomosis is highest when clips are used since they destroy a much smaller segment of the tube.
When pregnancy is desired after tubal ligation, in vitro fertilization (IVF) offers a greater likelihood of pregnancy than tubal microplasty. However, when multiple future pregnancies are desired, tubuloplasty may be a more economical alternative than multiple IVF cycles.
In 1985, the no-scalpel vasectomy technique was introduced.
With this procedure both vas are ligated through a single small midline incision that reduces the already low rate of complica- tions associated with vasectomy
Although not contra- indicated, Depo-Provera should be used with caution in pa- tients with
a history of depression, mood disorders, PMS, and premenstrual dysphoric disorder (PMDD). Similarly, Depo-Provera use is not contraindicated in obese women, but weight monitoring should be employed when using the medicine in women who may be at an increased risk for weight gain.
The female condom (FC; formerly the Reality Vaginal Pouch) is
a pouch made of polyurethane that has a flexible ring at each end. One ring fits into the depth of the vagina, and the other stays outside the vagina near the introitus (Fig. 24-3).
These benefits include
a reduced incidence of ovarian cancer, endometrial cancer, ectopic pregnancy, PID, and benign breast disease By taking OCPs, nearly 50,000 women avoid hospitalizations; of these, 10,000 avoid hospitalization for life- threatening illnesses.
Because the tubal blockage is accomplished over time, a backup method of birth control is recommended for 3 months
after the procedure until such time that a hysterosalpingogram (HSG) can confirm coil location and complete tubal occlusion. Some patients are reassured by this confirmatory test, whereas others are burdened by the additional step to achieving permanent sterilization. Prior to the procedure, patients should understand that tubal occlusion by this method is essentially irreversible.
It is anticipated that 50% of DMPA users will have amenorrhea after 1 year of use
and 80% after 5 years of DMPA use. However, the possibility of amenorrhea makes Depo-Provera a good option for women with bleeding disorders, women on anticoagulation, women in the military, and women who are mentally or physically disabled.
Hormonal contraceptives are the most commonly used reversible means of preventing pregnancy in the United States
and consist of combined (estrogen and progesterone) and progesterone-only methods.
Condoms
are latex sheaths placed over the erect penis before ejaculation. They prevent the ejaculate from being released into the reproductive tract of the woman.
increased incidence of gall bladder disease and benign hepatic tumors
associated with oral contraceptive use.
One disadvantage is that it is
available by prescription only.
Laparoscopically, there are a number of methods by which tubal occlusion can be accom- plished including
bipolar cautery (Fig. 24-13), Silastic banding with Falope rings (Fig. 24-14), or clipping with Hulka clips or Filshie clips
Cervical cap is held in place
by suction and acts as a barrier to sperm. The cap must be fitted by a clinician and must be used with a spermicidal jelly. Because of the variability in cervix size, proper fit and usage of the cap are essential to its effectiveness. Although it is widely used in Britain and Europe, the cervical cap is not widely avail- able in the United States.
It differs from ECPs in that it
can be continued for long-term contraception (10 years), whereas the ECPs have a one-time-only use.
Emergency IUD insertion The Copper T IUD
can be inserted in the uterine cavity within 120 hours (or 5 days) of unprotected intercourse as a form of emergency contraception
Disadvantages include
cardiovascular complications, in- creased gallbladder disease, increased incidence of benign hepatic tumors, and the need to take a medication every day.
Oral contraceptives with estrogen doses greater than 50 mg can increase
coagulability, leading to higher rates of myocardial infarction, stroke, thromboembolism, and pulmonary embolism, particularly in women who smoke.
Drawbacks of the condom include
coital interruption and possible decreased sensation or hypersensitivity.
POPs are generally not as effective as
combination hormone regimens, with failure rates estimated at greater than 8%. This failure rate increases if punctual dosing is not achieved
EC can also be used safely in women in whom
continual estrogen might otherwise be contraindicated, such as women with a history of DVT, PE, myocardial infarction (MI), stroke, or migraines with auras.
Vaginal Estrogen and Progestin Hormonal Contraception—NuvaRing The hormone-releasing vaginal ring (Fig. 24-11) with the brand name of NuvaRing releases a
daily dose of 15 mcg of ethinyl estradiol and 120 mcg of etonogestrel (the active form of desogestrel).
The actual efficacy rate of the cervical cap is 68% to 84% (16% to 32% failure rate)
depending on the woman's parity. There is an increased risk of failure in parous women. Dislodgment is the most common cause of failure.
The mechanism of action for ECPs
depends on the point during the cycle when the pills are taken.
vaginal ring is highly
effective (1% to 2% failure rate in actual use), similar to other forms of combined hormonal contraception.
Of all the oral EC regimens, the progesterone-only formulations (Plan B) are the most
effective and have fewer side effects. Thus, Plan B One Step should be used as a first choice when it is available, rather than using a combination method.
The IUD functions primarily by
eliciting a sterile inflammatory re- sponse within the uterus, making the environment unsuitable for fertilization.
ECPs use high doses of both
estrogen and progestins or progesterone alone (Plan B One Step, Next Choice) to prevent pregnancy after unprotected intercourse has taken place.
The progestin used in Nexplanon is
etonogestrel, the same progestin as used in the NuvaRing. The device is 4 cm x 2 mm, contains 68 mg of etonogestrel, and provides a slow release of hormone over 3 years. It is radiopaque and the size of a matchstick . It has a redesigned applicator that facilitates placement in the subdermal skin of the inner side of a woman's upper arm.
Emergency Copper T IUD insertion is
extremely effective, even more effective than the oral regimens.
Monophasic combination pills contain
fixed dose of estrogen and a fixed dose of progestin in each tablet. Nearly 30 combinations of estrogen and progestins are available in the United States.
Oral contraceptives place the body in a pseudo-preg- nancy state by interfering with the pulsatile release of
follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary.
Because they contain no estrogen, POPs are ideal for
for nursing mothers and women for whom estrogens are contraindicated, including women over 35 years who smoke and women with hypertension, coronary artery disease, collagen vascular disorder (CVD), lupus, migraines, and those with a personal history of thromboembolism.
Although mifepris- tone
has been approved in the United States for the termination of pregnancy up to 49 days of gestation, its use has not been approved for EC. In the United States, EC does not require an examination by a provider, although a pregnancy test should be performed before placing a Copper IUD or giving ulipristal (Ella)..
Even at lower doses of estrogen (35 mcg or less), women over 35 years who smoke more than one pack of cigarettes per day are still at increased risk of
heart attack, stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE) if they use OCPs. The progestins in oral contraceptives have been found to raise low-density lipoproteins while lowering high-density lipoproteins in pill users smoking more than one pack per day
Several differing regimens exist including those using
high doses of regularly prescribed OCPs and some using prepackaged regimens.
Nexplanon is one of the most
highly effective reversible con- traceptive methods, with only a 0.5% failure rate.
Side effects of condoms
hypersensitivity to the latex, lubricant, or spermicide in condoms.
Tubal ligation can be performed in the
immedi- ate postpartum period (postpartum sterilization [PPS]), or outside the postpartum period via a laparoscopic approach (laparoscopic tubal ligation [LTL]) or via hysteroscopic tubal occlusion (Essure).
This procedure may be performed
in a provider's office under local anesthesia through a small incision in the upper outer aspect of each scrotum
Spermicides may be used alone but are far more effective when used in conjunction with condoms, cervical caps, diaphragms, or other contracep- tive methods.
in actual usage, the efficacy of spermicides when used alone is only 70% to 75%. This effectiveness is further reduced by failure to wait long enough for the spermicide to disperse in the vagina prior to intercourse.
When the laparoscopic approach is under- taken, the Falope ring has been found to be most effective
in women under age 28 years.
Side effects of the progesterone-only OCP
include irregular ovulatory cycles, breakthrough bleeding, increased formation of follicular cysts, and acne breast tenderness and irritability.
The disadvantages of Nexplanon
include the need for a provider to insert and remove the device and the unpredictable bleeding profile.
The major disadvantages of ECPs
include the short window of time when they can be used (within 72 to 120 hours of in- tercourse). Additionally, these cannot be used as long-term contraception.
The major advantages of OCPs include
include their extremely high efficacy rates and the noncontraceptive health benefits primarily attributable to an overall decreased rate of pregnancy, menstrual flow, dysmenorrhea, and ovulation.
Depo-Provera (150 mg/1 mL, intramuscular "IM") is injected
intramuscularly every 3 months in a vehicle that allows the slow release of progestin over a 3-month period.
The disadvantages include
irregular menses ranging from amenorrhea to irregular spotting. Also, POPs must be taken at the same time each day. A delay of more than 3 hours is akin to a missed pill.
The primary side effects experienced by Depo-Provera us- ers include
irregular menstrual bleeding, depression, weight gain, hair loss, and headache
failure rate of the female condom
is 20% to 25%, somewhat higher than that of the male condom
The vaginal diaphragm
is a dome-shaped latex rubber sheet stretched over a thin coiled rim.
Periodic abstinence (the rhythm or calendar method)
is a physiologic form of contraception that emphasizes fertility aware- ness and abstinence shortly before and after the estimated ovulation period. This method requires instruction on the physiology of menstruation and conception and on methods of determining ovulation. It also requires the woman to have regular, predictable menstrual cycles.
Emergency contraception
is a safe and effective means of preventing pregnancy after unprotected intercourse or in the case of contraceptive failure (condom break, diaphragm dislodgment, IUD expulsion, missed pill, and late Depo-Provera injection).
The cervical cap (FemCap, Lea's Shield)
is a small, soft, silicone cap that fits directly over the cervix (Fig. 24-5).
Jadelle
is a two-rod implantable subdermal device also ap- proved by the FDA.
Coitus interruptus, or withdrawal of the penis from the vagina before ejaculation,
is one of the oldest methods of contraception. With this method, the majority of semen is deposited outside of the female reproductive tract with the intent of preventing fertilization.
The primary advantages of Depo-Provera are that
it is highly effective, acts independent of intercourse, and requires infrequent injections (every 3 months).
The primary disadvantage of coitus interruptus is
its high failure rate. Other disadvantages include the need for sufficient self-control to withdraw the penis before ejaculation.
The side effects of the pro- gesterone-only formulations are
less severe than symptoms ex- perienced with estrogen and progesterone-containing methods
For those using ECPs,
levonorgestrel methods are preferred over estrogen-progesterone regimens since levonorgestrel is more effective and has fewer side effects.
Jadelle uses
levonorgestrel to provide 5 years of con- traceptive coverage. At this time, Jadelle has not yet been marketed in the United States but has been used in many other countries.
Vasectomy is a simple and safe option for permanent sterilization involving
ligation of the vas deferens.
The IUD must be prescribed, inserted, and removed by a clinician. However, once in place, it is highly effective, cost-effective
long-lasting, and rapidly reversible. The user is encouraged to do a monthly string check to ensure the device has not been expelled. This improves coital spontaneity and decreases fear of pregnancy. In the United States, the ParaGard IUD has been approved for use for 10 years but has been shown to maintain its effectiveness for 12 years. The Mirena IUD has been approved for use for 5 years but is effective for at least 7 years. One IUD can be removed and another one can be inserted on the same visit. Also, an IUD may be inserted immediately after induced or spontaneous first trimester abortions without increased risk of infection or perforation.
The Essure procedure can often be performed in the office setting
making it a preferable option to surgical sterilization for all women, including obese women, women with prior abdominal surgeries, or those at risk from anesthesia use.
When pregnan- cies occur after vasectomy,
many are due to having intercourse too soon after vasectomy rather propr to azoospermia than from recanalization of the vas deferens.
Women with menstrual-related disorders (such as endometriosis, menorrhagia, anemia, dysmenorrhea, menstrual irregularity, menstrual migraines, premenstrual syndrome [PMS], polycystic ovary syndrome [PCOS], or ovarian cysts)
may benefit from extending the number of consecutive days of hormonal pills taken from 21 days to 1, 2, or 3 months, thus increasing the length of continuous hormonal suppression and decreasing the number of withdrawal bleeds. These extended or long-cycle regimens provide continued suppres- sion of ovulation and decreased menstrual-related symptoms (such as pain, heavy bleeding, anemia, and headaches) for their users.
Ovulation assessment methods
may include the use of ovulation prediction kits, basal body temperature measurements (Fig. 24-1), menstrual cycle tracking, cervical mucus evaluation, and/or documentation of any premenstrual or ovulatory symptoms.
Sterilization is ideal in stable
monogamous relationships where (no additional) children are desired. It is also indicated in women in whom pregnancy would be life-threatening such as those with major cardiac issues.
Copper T is not an acceptable form of emergency contra- ception in women who are not candidates for IUDs, including those with
multiple sexual partners, suspected active cervical or uterine infections, and victims of rape.
The primary side effects of EC include
nausea (50%), vomiting (20%), headaches, dizziness, and breast tenderness.
Because they contain estrogen, combination OCPs are not suitable for many women. Many women also complain of
nausea, headaches, breakthrough bleeding, and weight gain associated with OCP use. Most of these symptoms are generally mild and transient.
Advantages of its use include
one-time dosing and relatively mild side effects.
While there are relative and absolute contraindications for use of
oral contraceptives in women with certain medical con- ditions (history of stroke, heart attack, DVT, and PE), these contraindications do not apply to women using emergency contraceptives. However, repeated use of ECP is not recom- mended in this high-risk group.
Progesterone-only contraception consists of
oral, injectable, implantable, and intrauterine options These all function primarily using the same mechanisms: thickening the cervical mucus, inhibit- ing sperm motility, and thinning the endometrial lining so that it is not suitable for implantation.
Electrocautery and Falope rings are equally effective in women
over age 28.
The ECPs may be obtained
over-the-counter without a prescription by men and women 17 years or older
After an injection,
ovulation does not occur for 14 weeks; therefore, patients have a 2-week grace period in their every 12-week dosing.
Because sperm can remain viable in the proximal collecting system after vasectomy,
patients should use another form of contraception until azoospermia is confirmed by semen analysis, usually in 6 to 8 weeks.
Tubal ligation has a failure rate of 0.3% but varies by method, patient age, and surgeon's experience. The highest success rates are achieved with
postpartum sterilization and Essure tubal occlusion
Emergency contraception is used to
prevent pregnancy by inhibiting ovulation, interfering with fertilization and tubal transport, preventing implantation, or causing regression of the corpus luteum
Oral contraceptive pills (OCPs) are composed of
progesterone alone or a combination of progesterone and estrogen.
The failure rate for coitus interruptus is
quite high (27%) compared to other forms of contraception. Failure can be attributed to the deposition of semen (pre-ejaculate) into the vagina before orgasm, or the deposition of semen near the introitus after intracrural intercourse.
The average effectiveness of periodic abstinence is
relatively low (55% to 80%) compared to other forms of pregnancy prevention
The major risks of tubal ligation are those associated with surgery including the
risk of infection, hemorrhage, conversion to laparotomy, viscus injury, vascular damage, and anesthesia complications.
The risk of pregnancy is reduced by 75% to 90% in women who have had unprotected intercourse during the
second or third week of their menstrual cycles, when they are most likely ovulating.
Complications after vasectomy are rare and usually involve
slight bleeding, skin infection, and reactions to the sutures or local anesthesia. Fifty percent of patients form antisperm antibodies after the procedure. However, there are no long- term side effects of vasectomy.
DMPA is especially useful in women who desire effective contraception, but may have concomitant medical conditions that prevent the use of estrogen-containing contraceptives,
such as women with migraines with auras, seizure disorders, lupus, sickle cell disease, hypertension, coronary artery dis- ease, and smokers.
This pseudo-pregnancy state
suppresses ovulation and prevents pregnancy from occurring. Because the FSH and LH surges do not occur, follicle growth, recruitment, and ovulation do not occur. The bleeding that takes place during the hormone-free interval is actually a bleed due to the withdrawal of hormone rather than a menstrual period induced by endogenous hormone fluctuation.
Depo-Provera acts by
suppressing ovulation, thickening the cervical mucus, making the endometrium unsuitable for implantation, and reducing tubal motility
Tubal sterilization prevents pregnancy by
surgically occluding both fallopian tubes to prevent the ovum and sperm from uniting.
POPs also differ from traditional pills in that they are
taken every day of the cycle with no hormone-free days.
Studies show that Plan B is equally effective if
taken in a single dose with minimal increased side effects. Regardless of the regimen, the first dose must be taken within 72 hours of unprotected vaginal inter- course. There is some additional efficacy if initiated within 120 hours, although not as high as within the first 72 hours. An antiemetic is often prescribed at the same time to prevent nausea (more common in estrogen-containing regimens).
One advantage of the cervical cap is
that it can be inserted up to 6 hours prior to intercourse and can be left in place for 1 to 2 days. However, a foul discharge often develops after the first day. The cap must be refitted after a pregnancy or in the event of large weight change. Also, many women have a difficult time mastering the placement and removal techniques for the cervical cap; as a result, the continuation rate is low (30% to 50%).
The major advantage of Nexplanon is
that it is implantable and provides three uninterrupted years of contraceptive coverage. There is no maintenance associated with the device and thus no interruption of sexual spontaneity.
The advantage of the multiphasic dosing is
that it may provide a lower level of estrogen and progestin overall, but is still highly effective at preventing pregnancy.
Disadvantages of IUD are
that it must be placed by a provider, it has a higher one-time cost than oral regimens, and its potential for rare complications such as infection and perforation (described in the IUD section above). The ParaGard IUD is also associated with heavier menses and dysmenorrhea.
Failure rate for lactational amenorrhea
the failure rates for actual practice are so high
The combination pill containing both estrogen and progestin is taken for
the first 21 days out of a 28-day monthly cycle. During the last 7 days of the cycle, a placebo pill or no pill is taken. Bleeding should begin within 3 to 5 days of completion of the 21 days of hormones.
Most of these symptoms are thought to be secondary to
the high doses of estrogen in the combined regimens.
In general, the selection of a particular pill depends on
the individual side effects and risk factors for each patient.
Cur- rently, only two IUDs are available in the United States
the intrauterine Copper-T IUD (TCu-380A or ParaGard) and the levonorgestrel intrauterine system (LNG-20 or Mirena). Despite previous fears, there are nearly 100 million IUD users globally, making the IUD the most widely used method of reversible contraception in the world (Fig. 24-7).
The advantages include
the lack of general anesthesia and the lack of a surgical incision. As a result, when hysteroscopic tubal sterilization/occlusion can be performed, very little recuperative time is needed and it provides a safer, more effective means of permanent birth control.
After discontinuation of Depo-Provera injections, some women may experience a significant delay in
the return of regular ovulation (range of 6 to 18 months; average of 10 months). This is independent of the number of injections but may be directly related to the weight of the patient. Within 18 months, however, fertility rates return to normal levels.
Like other progestins, Depo-Provera reduces
the risk of endometrial cancer and PID and also the amount of menstrual bleeding
OCPs are remarkably effective in preventing pregnancy.
the theoretical failure rate for the first year of use is less than 1%. However, the failure rate with actual real-life usage is closer to 8%. Nausea, breakthrough bleeding, and the neces- sity of taking the pill every day are often cited as reasons for discontinuing the pill.
periodic abstinence, coitus interruptus, and lactational amenorrhea—are physiology-based methods that use neither chemical nor me- chanical barriers to contraception.
these are the least effective methods of contraception and should not be used if pregnancy prevention is a high priority.
Multiphasic oral contraceptives differ from monophasic pills only in that
they vary the dosage of estrogen and/or progestin in the active hormone pills in an effort to mimic the menstrual cycle.
Secondary mechanisms of action for OCPs include thickening the cervical mucus
to render it less penetrable by sperm and changing the endometrium to make it unsuitable for implantation.
In addition to their contraceptive benefits, POPs can be used to
treat abnormal uterine bleeding in high risk medical populations whose bleeding has been adequately evaluated (i.e., anovula- tory bleeding and endometrial hyperplasia in poor surgical candidates).
DMPA (Depo-Provera) is also useful in
treatment of menorrhagia, dysmenorrhea, endometriosis, menstrual-related anemia, and endometrial hyperplasia.
Over 150 million women worldwide—including one-third of sexually active women in the United States—
use oral contraceptives.
Unlike female tubal ligations,
va-sectomy is not immediately effective.
Currently, combined hormonal methods are available in oral, transdermal, and vaginal forms,
whereas progesterone-only methods are available in oral, injectable, implantable, and intrauterine forms.
Ulipristal is contraindicated in women
who are breastfeeding or currently pregnant, given its antiprogestin effects and po- tential to terminate an existing pregnancy A pregnancy test is required before the administration of ulipristal
The rate of sterilization is higher in women
who are married, divorced, over age 30, or African-American.
The IUD is especially indicated for women in
whom oral contraceptives are contraindicated, those who are at low risk for STIs, and in monogamous women of any age. The levonorgestrel-containing IUD (Mirena) can also be used to treat menorrhagia, dysmenorrhea, and also used in postmenopausal women receiving estrogen therapy
The pregnancy rate when prescribed EPRM
within the 120-hour window is about 2%.
oral contraceptives are contraindicated in
women over age 35 years who smoke 15 or more cigarettes a day.
