Contraception: A problem-based approach

Alice Chuang, MD, FACOG

Department of Obstetrics & Gynecology

Division of Women’s Primary Health Care

Case 1:A 23 year old presents to your office for her annual exam. She tells you that she has concerns about taking the Pill because a friend of hers just had a blood clot in her leg while on the Pill. She would like another form of birth control. She is married; she has completed her childbearing. She was originally placed on the pill because she had heavy menstrual cycles. You suggest:

a) A different brand of oral contraceptiveb) The Mirena IUDc) The copper IUDd) A tubal ligation

Objectives:

Be able to describe and list the many available forms of contraception

Be able to discuss their advantages and disadvantages

Be able to select the right method of birth control to improve patient compliance and satisfaction

Contraception: introduction

48% of pregnancies in the US are unintended

In 2000, 25% of all pregnancies ended with an induced abortion.

We are doing a bad job of preventing unintended pregnancy!

Contraception: introduction

With unprotected intercourse:After 1 year, 85% of couples will get

pregnantDuring menses, 1% chance of pregnancy

per act of unprotected coitus Midcycle, 17-30% chance of pregnancy per

act of unprotected coitus

What is the perfect form of contraception?

Reversible v. irreversible

Hormonal v. nonhormonal

Low maintenance v. high maintenance

It depends on the individual patient!

Case 2:

A 29 year old presents to your office for her annual exam with no complaints. When asked if she is sexually active, she replies that she is. When asked if she needs contraception, she states no. You:

a) Stress that contraception is important in order to prevent pregnancy.

b) Ask her if she is planning to get pregnant because if not, then she needs contraception.

c) Remind her that the natural family planning is not very effective at preventing pregnancy.

Case 3:

A 38 year old presents to your office for her annual exam. She would like some contraceptive recommendations. She has completed her childbearing and wants to have her tubes tied. You suggest the IUD, but she feels strange “having something inside her.”

You suggest:

Tubal ligationFailure rates 0.8% postpartum salpingectomy 3.7% Hulka spring clip

Mechanism: occlusion/interruption

Pros: permanent, highly effective

Cons: requires surgery, risk of ectopic pregnancy with failure, not reversible, does not prevent STI’s, risk of regret

US Collaborative Review of Sterilization. The risk of pregnancy after tubal sterilization. Am J Obstet Gynecol 1996:174:1161-70

                                                               

                                  

Essure (transcervical sterilizaton)

Failure rates: 0 (n=453)

Mechanism: polyester fibers (PET) placed hysteroscopically induce local tissue growth and tubal blockage

Essure (transcervical sterilization)Pros: highly effective, office procedure with rapid recovery, average procedure time = 13 minutes

Cons: May require more than one procedure, tubal spasm, possible expulsion, need verification of occlusion with hysterosalpinogram 3 months afterwards, very difficult to reverse

VasectomyFailure rate: 0.15% in first year

Mechanism: interrupting vas deferens

Pros: simpler, safer than female sterilization

Cons: use backup method until sperm count = 0, possible regret, requires surgery, does not prevent STI’s

Case 4:

A healthy 25 year old presents to your office for her annual exam. She is getting married in 3 months and is not ready to start a family, but would like to in a few years. She has a cousin who recently got married and is using the patch, but she does not “trust” these newer methods of birth control.

You offer her…

The Pill (ethinyl estradiol/various progestins)

Efficacy: 0.3-8%

Mechanism: inhibit ovulation, thickens cervical mucus, decreases tubal mobility, thins endometrium

The Pill (ethinyl estradiol/various progestins)

Pros: Decreased anemia, dysmenorrhea, mittelschmerz, benign breast disease, ovarian cancer, endometrial cancer, decreased corpus luteum cysts, decreased death from colorectal cancer

Cons: No protection against STI’s, daily oral dosing,

The Pill (ethinyl estradiol/various progestins)

Absolute contraindications: Pregnancy Previous or active thromboembolic disease Undiagnosed genital bleeding Smoking and age >35 Estrogen dependent neoplasm Hepatoma

Relative contraindiations: Hypertention Diabetes Gallbladder disease Obesity Migraines

Case 5:

A healthy 25 year old presents to your office for her annual exam. She is getting married in 3 months and is not ready to start a family, but would like to in a few years. She has used condoms in the past but really would like something a little lower maintenance. She has thought about the pill, but is concerned she would forget to take it daily.

You offer her…

Nuvaring (ethinyl estradiol/etonogestrel)

Failure rate: 0.3-0.65%

Mechanism: same as OCP’s

Pros: only requires insertion/removal, lowest estrogen/progestin dose of any combined hormonal method, comfortable for both partners during intercourse

Cons: 25% of cycles accompanied by additional spotting, possible expulsion, does not prevent STI’s

Ortho Evra (ethinyl estradiol/norelgestromin)

Failure rate: 0.3-8.0%Mechanism: same as OCP’sPros: requires weekly maintenance, proven better complianceCons: application site problems, increased nausea and breast tenderness compared to oral contraceptives, does not prevent STI’s, lower efficacy in women > 90kg

Case 6:

A 25 year old presents to your office for her annual exam. She is married and does not plan to have any more children for at least the next 5 years. She has been on the pill before but would like something low maintenance. She is not interested in any of those “new-fangled” methods like the Patch and that “ring.”

You suggest:

Mirena IUD (levonorgestrel)

Failure rate: 0.1%Mechanism: Thickens cervical mucus, alters tubal motility, thins endometrium, inhibits ovulation (5-15% of cycles)Pros: Decreased menorrhagia, dysmenorrhea; low maintenance, extremely effectiveCons: Initial increase in spotting, bleeding; possible amenorrhea (20% after 1 year), possible expulsion, possible perforation with placement and migration afterwards

Paraguard T380 (copper IUD )

Failure rate: 0.6%Mechanism: spermicidal effect of copper ionsPros: low maintenance, cost effective, lasts for 10 years, Cons: increased menstrual bleeding and dysmenorrhea, possible perforation at placement or migration later

Case 7:

A 24 year old presents to your office for her annual exam. Her fiance is stationed overseas. She would like a method that she can use only when he is in town. She does not want to be on the Pill.

You suggest:

Diaphragm

Failure rate: 6-16%

Mechanism: Mechanical barrier, spermicide

Pros: non-hormonal,

Cons: high-maintenance, requires placement prior to act of intercourse and high level of patient skill

Condom

Failure rate: 2-15%

Mechanism: barrier

Advantages: Protects against STI’s, no hormonal side effects

Disadvantages: Successful use based on education/experience; 3-5% risk of breakage/slippage

Case 8:

A 23 year old presents to your office for her annual exam. She will be getting married next month, and her religion precludes her from using any form of conventional birth control. She is not ready to have children. She needs some advice.

You offer her:

Natural Family Planning

Failure rate: 1-25%

Mechanism: Timing of intercourse

Pros: inexpensive

Cons: Difficult to use for the average patient, relatively high failure rate,

Case 9:

A 23 year old calls your office because she had intercourse last night, and the condom broke.

You offer her:

Emergency Contraception

OptionsPlan B: Progesterone

onlyYuzpe Method/Preven:

Estrogen + progesteroneCopper IUD

Emergency Contraception

COC’s Plan B Copper IUD

TimingASAP, but can be used up to 3-4 days

ASAP but can be used up to 5 days

Up to 8 days

Effectiveness(pregnancies/

100 women)

0.4% (<12 hrs)

Average 2-3.2%

0.5% (< 12 hrs)

Average: 1.1%0.1%

AdvantagesWide range of possible pills

Fewer side effects, both doses can be taken at once

Effective, provides contraception afterwards

DisadvantagesGastrointestinal side effects, spotting

Less available, spotting,

Expensive, insertion required, may have spotting

Hatcher RA, Zieman M et al. Emergency Contraception. In A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundtiona, 2005

Emergency Contraception: Mechanism of Action

If taken before ovulation:Disrupts follicular developmentBlocks LH surge, thus inhibiting ovulationThickening cervical mucus Inhibits tubal motility

If taken after ovulation:Has little effect

Emergency Contraception does not work by disrupting an implanted pregnancy!

Case 1:A 23 year old presents to your office for her annual exam. She tells you that she has concerns about taking the Pill because a friend of hers just had a blood clot in her leg while on the Pill. She would like another form of birth control that does not have hormones. She is married; she has completed her childbearing. She was originally placed on the pill because she had heavy menstrual cycles. You suggest:

a) A different brand of oral contraceptiveb) The Mirena IUDc) The copper IUDd) A tubal ligation

Poor choices

Irreversible: Tubal ligation Essure Vasectomy

Hormonal: OCP’s Ortho Evra Nuvaring

High maintenance Diaphragm Cervical cap Natural family

planning

The Answer:

Mirena IUD!

Highly effective, low maintenance, decreased menorrhagia and dysmenorrhea, only localized hormonal effect, and reversible