Post on 18-Dec-2015
Rationale
An understanding of the medical and personal issues involved in decisions regarding contraceptive methods is necessary to adequately advise patients requesting contraception.
Objectives
The student will be able to explain:
1. Physiologic and pharmacologic basis of action
2. Effectiveness
3. Benefits and risks
4. Financial considerations of the various methods of contraception
Contraception in the United States 64% of women ages 15-44 use some form of
contraception Contraceptive Methods (percentage of users for each
method) Sterilization
• Female (27%) • Male (12%)
Oral Contraceptive Pills (OCPs) (27%) Condoms (20%) Intrauterine Device (1%) Depo Provera Injections (3%) Other (10%)
Contraception in the United States Mechanism - No exposure to sperm during
fertile period Failure - 19% during first year of use Advantages - low cost, managed by patient
herself Disadvantages
High failure rate in unmotivated Variability between menstrual cycles
Barrier Methods
Prevent sperm and ova from mating Condoms
• Protect against STDs• Male
• Failure rates • Perfect - 3% • Typical - 16%
• Cost $1-$10 depending on brand/type
Barrier Methods
Condoms Female
• Failure rates • Perfect - 5% • Typical - 21%
• Cost $2-$3 each; use with each intercourse act
Barrier Methods
Diaphragm Used in conjunction with spermicide Failure rates
• Perfect - 6% • Typical - 18%
Advantage - low cost $30-$40 Disadvantage - increased rate of UTI,
needs to be fitted by MD act
Barrier Methods Cervical Cap
Failure rates • Perfect use /Typical use• Nulliparous 9% / 20% • Multiparous 26% / 40%
Disadvantages • Must have normal PAP smear • Must be fitted initially by MD • High failure rate in multiparous patient
Cost approximately $30, plus office visit
Oral Contraceptive Pills
Mechanism of action Blocks mid-cycle gonadotropin surge Thickens cervical mucus Alters uterine and tubal motility Creates hostile endometrium (impairs
blastocyst survival)
Oral Contraceptive Pills Contraindications
Deep vein thrombosis (DVT) or pulmonary embolus(PE)
• Current or in past Cerebrovascular disease Uncontrolled hypertension or coronary artery disease Migraine with focal neurological symptoms Congestive heart failure Age > 35 and smoker Estrogen - dependent neoplasm Undiagnosed vaginal bleeding Pregnancy Active liver disease
Oral Contraceptive Pills Advantages
Decreased incidence of endometrial cancer Decreased incidence of ovarian cancer Less dysmenorrhea Less PMS/PMDD Decreased amount of menstrual flow Decreased incidence of functional ovarian cysts Decrease in benign breast disease Decreased incidence of pelvic inflammatory disease
(PID) Decrease in acne
Oral Contraceptive Pills
Disadvantages $30 per month ? Increase in breast cancer if used >4 years
under age 25 ? Increase in cervical cancer with prolonged
use
Progestins (long acting)
Mechanism of action Inhibit ovulation Thickens cervical mucus Thins endometrium
Progestins: TypesDepo-Provera (Injection every 12-14 weeks) Advantages
Reversible Good safety profile Effective - 0.3% failure rate
Disadvantages Irregular bleeding Amenorrhea Breast tenderness Weight gain (up to 5 lbs per year) Depression Possible slow return to fertility
Cost $40 every 3 months
Progestins: TypesDepo-Provera (Injection every 12-14 weeks) Norplant
6 rods in arm Not currently available in United States
Implanon Single rod in arm FDA approved, but not used in U.S. yet
• Usually improves within 3 cycles • Only during first 21 days after insertion • Increased risk of septic abortion if IUD not removed • Higher percentage of pregnancies are ectopics
Emergency contraception Given within 72 hours of unprotected intercourse 90% effective Side effects
Nausea and vomiting Breast tenderness Headache Dizziness
Examples Ovral - 2 pills q 12 hours x 2 doses
IUD inserted within 5 days of unprotected intercourse 0.1% failure rate
Intrauterine Device
Mechanism of action Inhibit sperm motility Hostile uterine environment for sperm May inhibit ovulation (Mirena)
Intrauterine Device Contraindications to insertion
Pregnancy Distortion of the uterine cavity Acute pelvic inflammatory disease Other uterine infections Uterine or cervical cancer Unresolved abnormal PAP smear Untreated acute cervicitis or vaginitis Wilson’s disease or allergy to copper (ParaGard) Genital actinomycosis Multiple sexual partners or partner with multiple sexual partners Immunosuppression (AIDS, leukemia, IV drug use) Previous IUD still in place
Intrauterine Device Failure rate <1% Advantages
Duration 10 years (ParaGard), or 5 years (Mirena)
Low maintenance Low cost per year of use (approximately
$300-$500 initial cost) Decreased menstrual flow (Mirena)
Intrauterine Device Disadvantages
Increased menstrual flow (ParaGard) Increased menstrual cramping
• Usually improves within 3 cycles Does not protect against STDs Increased risk of infection
• Only during first 21 days after insertion Requires office procedure for insertion/removal
Intrauterine Device Special consideration
Pregnancy with an IUD in place• Increased risk of septic abortion if IUD not
removed • Higher percentage of pregnancies are ectopics
Rationale
In the process of deciding whether to have a sterilization procedure, men and women often seek the advice of their physicians. Providing accurate information will allow patients to make an informed decision regarding this elective surgery. Sterilization is the most common form of contraception used by married couples
ObjectivesThe student will be able to list: Methods of male and female surgical sterilization Risks and benefits of procedures Factors needed to help the patient make informed
decisions, including: Potential surgical complications Failure rates Reversibility
Financial considerations
Female Sterilization - Types
Tubal ligation and/or resection Methods
Laparoscopy Minilaparotomy Colpotomy
Female Sterilization - TypesTubal ligation and/or resection Advantages
Immediately effective Very effective and permanent Can be done on ambulatory basis
Disadvantages Anesthesia risks Potential for perforation of organs Potential for emergency hospitalization Potential for bleeding Potential for infection
Female Sterilization - TypesTubal ligation and/or resection Tubal ligation types
Modified Pomeroy - knuckle of tube tied and then resected
Parkland - bilateral mid segmental salpingectomy Madlener - crush and ligate midsection of tube
(only of historic value - high failure rate) Irving - ligate tube and bury proximal stump in the uterine
myometrium Uchida - removal of isthmic portion of tube and burying
proximal stump in mesosalpinx
Female Sterilization - Types
Tubal occlusion - simple occlusion using silasticrings or tubal clips
Silastic rings (Yoon) - place in isthmic portion of tube Tubal clip (Hulka or Filshie) - place in isthmic portion
of tube Advantage - simple, safe, minimal amount of tubal
destruction
Female Sterilization Possible complications
General anesthesia Intraoperative injuries
• From trocar• Mesosalpingeal tears
Infection Ectopic pregnancy
• Failed sterilization procedures account for less than 2% of all ectopic pregnancies
Male Sterilization - vasectomy 500,000 performed annually Transection of vas deferens Not sterile until two sperm-free ejaculates, 30 days apart Advantages
Local anesthetic Office procedure
Disadvantages 5% hematoma Sperm granulomas Epididymitis
10% request reversal with a 40% success rate Failure rates - up to 6%
References - Contraception Speroff L. Oral contraceptives and venous
thromboembolism. International Journal of Gynecology and Obstetrics. 54(1):445-50, Jul. 1996.
Piegsa K, Guillebaud J. Oral contraceptives and the risk of DVT. Practitioner. 240(1566):544-51, Sep. 1996.
Suissa S, Blais L. First-time use of newer oral contraceptives and the risk of venous thromboembolism. Contraception. 56(3):141-6, Sep. 1997.
References - Sterilization Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR,
Turssell J. “The risk of after tubal sterilization: findings from the U.S. collaborative review of sterilization”. American Journal of Obstetrics and Gynecology, April 1996, 174, No. 4: 1161-1170.
Penfield JA. The Filshie Clip for female sterilization: a review of world experience. American Journal of Obstetrics and Gynecology, March 2000, 182, No. 3: 485-489.
Moore TR, Reiter RC, Rebar RW, Baker V. eds., Gynecology and Obstetrics: A Longitudinal Approach. New York: Churchill Livingstone, 1993.
Patient presentation
The patient is a 35-year-old G5P4 black woman with BMI > 30 who presents with complaints of severe right lower extremity pain. She reports she was in her usual state of health until about 5 days ago when she had onset of pain in her right lower extremity. The pain has progressively worsened especially in her calf over the past five days. She also has swelling, warmth and redness along her right lower extremity from the foot to mid-thigh. She reports no headaches, dizziness, chest pain, shortness of breath, cough, or dyspnea.
Patient presentationOb-Gyn history Spontaneous vaginal delivery times 4 Elective abortion Started OCP (Ortho Novum 7-7-7) about 1 year ago LMP 1 year ago Negative Pap smear & STD screen
Past medical history Varicose veins Pneumonia at the age 12
Patient presentationPast surgical history Cholecystectomy at age 30 Tonsillectomy at age 13
Social history H/o tobacco use times ½-pack per day for 10 years; quit 1 year ago No ETOH; no IVDA Works as a secretary for a paper company
Allergy and medication None
Family History No cancers, DM, CAD, CVA, or HTN, positive for DVT in her mother
Patient presentationPhysical Exam General: Obese black female in mild distress from leg pain. VS BP 130/80, RR18, P 86 and regular; wt: 243 HEENT: PERRLA, NC, NT Chest: clear to auscultation and percussion Cardiovascular: Normal rate and rhythm, no murmurs Breasts: No masses, adenopathy or skin changes Abdomen: No hepatosplenomegaly, non-tender, obese Pelvic: External genitalia: Normal Vagina: Moist, pink, no discharge Cervix: Parous, no lesions Biman: Small, anteverted non-tender, no adnexal masses Extremities: Right lower extremity with posterior calf tenderness,
warmth, swelling, and increased pain during dorsiflexion of the foot.
Patient presentationLaboratory or studies Hbg 10.8 Hct 31.7 vol.% PT/ PTT 12 sec/ 55 se Protein S - pending Protein C - pending Von Willebrands - pending Lupus Anticoagulant - pending A duplex venous ultrasonography of her right lower
extremity showed occlusion of the popliteal vein.
Treatment The patient was immediately placed on heparin
anticoagulation. She was also started on coumadin and heparin was discontinued once she achieved therapeutic levels of coumadin. She was placed on oral anticoagulation for 6 months, and oral contraceptives were discontinued. She was offered a Paragard IUD vs. a tubal ligation.
Teaching Points
1. Combination oral contraception is contraindicated in women who have a history of idiopathic venous thromboembolism. In women who have a family history (this patient’s mother had a DVT), the World Health Organization gives a Category 2 rating: A condition where the advantages of using the method generally outweigh the theoretical or proven risks. Although the patient’s family history was not a contraindication to oral contraceptives, her personal history of a DVT now presents a contraindication.
Teaching Points
2. The rare woman on oral contraception who has a thrombotic episode may have an underlying clotting problem, such as abnormality of Factor V in the clotting cascade (Reference 2.) This patient is likely to have some kind of clotting factor deficiency because her mother has a history of DVT. She should undergo testing for these abnormalities.
Teaching Points
3. Risk factors for venous disease include (Reference 3.)
a. BMI > 30b. Immobilityc. Excessive varicositiesd. Family history of DVT in first-degree relative
under 45