KEN ROPERBSc(Med)MBBSFRANZCOGObstetrics,Gynaecology,ColposcopyandLaparoscopicSurgeryConjointLecturerUNSWProviderNumber458915B

32/2024GibbsStMiranda,NSW2228

Ph:95242129www.drkenroper.com.au

31stJanuary2012

ContraceptionFactSheet

Themainpurposeofcontraceptionistoavoidconceivingduringsexualactivity.Thiscanbeachievedbyanumberofways.Classificationsofcontraceptionaremanyandvaried.Theseincludenaturalversushormonal,permanentversusreversible,thoserequiringactiononlyduringintercourseandthoseindependentofintercourse.Therearecertainhealthconditions,pregnancyhistoryandageofthecouplethatmayprecludeparticularcontraceptivemethods.

Thefollowinginformationistobeseenasaguideonlyandisnotasubstituteforconsultationwithamedicalpractitioner.

PearlIndex

ThePearlIndexofacontraceptivetechniquereferstoitseffectiveness.Itiscalculatedasthenumberofwomenwhowillbecomepregnantper100womenperyearhavingregularsexualactivity.ForexampleaPearlIndexof2meansthatfora100coupleswhoareregularintercourse23timesperweekusingaparticularformofcontraceptionfor12monthsthattherewillbetwoofthemwhowillbecomepregnantduringthattime.ThereforethelowerthePearlIndexthegreaterdegreeofcontraceptionisbeingachieved.

Withdrawal/CoitusInterruptus

Thisisasurprisinglyfrequentlyusedformofcontraceptioninmanyagegroups.Ithasthebenefitsofbeingsimple,cheapandreadilyemployablebutthemarkeddisadvantageofpotentiallyreducedsexualenjoymentthroughfearofunintendedpregnancy.Timingiscriticalandunfortunatelytherearespermthatarereleasedfromthemalepenispriortoejaculationandthismaybeacontributingfactortoitsfailurerate.Astestimonytoitssuccessarethosepatientswhoimmediatelyconceiveaftercessationofusingthistechnique.

BillingsMethod

Thismethodreliesupontheobservationofthecervicalmucous.Aroundthetimeofovulationthismucousbecomesclear,moreslipperyandheavier.Thiswillusuallyoccur14dayspriortothenextmenstrualperiod(notnecessarily14daysafterthepreviousmenstrualperiodasthefirstpartofthemenstrualcyclecanvaryinitslength).Duringthistimeofperceivedovulationintercoursecaneitherbeavoidedoralternativemeasuressuchasbarriermethodsorwithdrawalused.Thistechniqueisparticularlyusefulforthosecoupleswherethewomenhasaregularmenstrualcycleandisalsoabletoobservethesechangesinhercervicalmucous.

Condoms

Theseareareadilyavailableformofcontraceptionwhichhavetheaddedbenefitofadegreeofprotectionagainstsomesexuallytransmittedinfections.Itisimportantthatcondomsareusedproperly.Theycandeteriorateifstoredinahotenvironment(eggloveboxofthecar),oriftheyruptureduringsexualactivity,oriftheyslipoffafterejaculationwhenthemalepenisisnolongererect.ThequotedPearlIndexforcondomsis515.

Diaphragm

Thecontraceptivediaphragmisusedlessfrequentlythesedays.Theydohavetheadvantageofbeingabletobeinsertedwellbeforesexualintercoursetakesplaceandtherebynotinterferewithforeplay.Theobviousdisadvantageiswhensexualintercoursehadnotbeenforeseenandthediaphragmnotcloseathand.Diaphragmsneedfittingbyahealthcareprofessionalsuchasageneralpractitioner,gynaecologistoraFamilyPlanningClinic.TheyhaveasimilarPearlindextocondomsof515.

EmergencyContraception

Themedication,Postinor2,isaprogesteronebasedtabletthatcanbeusedinthecontextofanemergencywheretherehasbeenunintendedunprotectedintercoursearoundthetimeofthecyclewhenthewomanbelievesshemaybefertile.Itismosteffectiveassoonafterintercoursehasoccurredbutstillmaybeeffectiveupto72hoursafterwards.Itdoesnotrequireaprescriptionandcanbeobtainedfrommostpharmacists.Thisformofcontraceptionisnottoberelieduponasaroutinecontraceptionbecauseofitspotentialforfailurebutalsobecauseofitspotentialforcausingmenstrualirregularities.

CombinedOralContraceptivePill

Thecombinedoralcontraceptivepillhasbeenavailableforapproximately50yearsandcontainsbothoestrogenandprogesterone.Theoestrogencomponentofthepillisresponsibleforinhibitingovulation.Theprogesteronecomponentwillpreventtheliningofthewomb(endometrium)frombecomingtoothick.Indeedoneofthebenefitsofthepillistocausereducedmenstrualbleedinginapredictablefashionandalsoreduceperiodpain.Itisimportanttotakethepillasdirected.WhileithasaPearlIndexof0.8thiscanbemadelesseffectivebyomissionofthepill,malabsorptionofthepillbecauseofvomitingordiarrhoea,theuseofcertainantibioticsandtheconcurrentuseofmedicationsthateffectthemetabolismofthepillintheliver(someanticonvulsantdrugsandmedicationsusedtotreattuberculosis).Thepilliscomparativelysafebuttherearesomewomenforwhomitsuseisdangeroussuchasapasthistoryofdocumenteddeepveinthrombosis/pulmonaryembolism,recentbreastcancer,highbloodpressure,heartdiseaseandmaybeanaddedriskfactorforhardeningofthearteries.Oneoftenutilisedadvantageofamonophasicpill(apillwhichhasthesamestrengthandproportionofhormoneineverysingletablet)isthatitispossibletomanipulatethelengthofyourmenstrualcyclebystayingonthepillforgreaterthantheusualthreeweeksandtherebypostponingaperiodforimportanteventssuchasexamsandholidays.Therearesomewomenwhoinattemptingcyclemanipulationwillstilldevelopaperiodandsimplyisnotgoingtobeeffectiveforthem.Thistechniqueisgenerallynotsuitableforwomenwhoareonatriphasicpill(onethathasthreedifferentstrengthsofhormonesthroughoutthecycle).Thecombinedoralcontraceptivepillcannotbeusedinlactationbecauseofthepotentialforsuppressionofmilkproductionbytheoestrogenthatisinthepill.

Nuvaring

Thisisarecentlydevelopedcontraceptionwherebyaplasticringthatisimpregnatedwithbothoestrogenandprogesteroneisplacedbythewomanherselfwithinhervagina.Theplasticringwillleachoutbothhormonesforbetween2124daysbeforeitisremovedforafullsevendaysandanewringinsertedthefollowingweek.Thebenefitsofthistechniqueisalowerhormonaldoseandagreaterlikelihoodofcompliance.Thesedevicesgenerallydonotfalloutnorcauseinfectionbutanumberofwomenfeelawkwardabouthavingthisdeviceinsidetheirvagina.Itdoesnotinterferewithsexualintercourse.ItisaPearlIndexsimilartothatoftheoralcontraceptivepillof0.8.

ProgesteroneOnlyPill(Minipill)

Theprogesteroneonlypillistypicallyusedinthecontextofabreastfeedingmotherbutalsoforwomenwhohaveahistoryofthrombosisorcardiacdiseaseforwhomanoestrogencontainingpillwouldcontributefurthertoworseningofthoseunderlyingmedicalconditions.UnfortunatelyithasahigherPearlIndexof45.Thispillistakeneverysingleday.Itisbelievedthatitscontraceptiveactionisduetothickeningofthecervicalmucousandpreventingpenetrationofspermintotheuterinecavity.Thetimingofdosageoftheprogesteroneonlypillisfarmorecriticalthanthatofthecombinedoralcontraceptivepill.Theprogesteroneonlypillwillneedapproximatelythreehourstobeeffectiveanditwillwearoutthreehourspriortothenextday'stablet.Itthereforeneedstobetakenatthesametimeeverysingledaybutalsointercourseavoidedboththreehoursbeforeandthreehoursaftertakingthispill.

Implanon

Thisisahighlyeffectiveandquicklyreversiblecontraceptiveoption.Thisisaplasticrodthesizeofamatchstickthatisinsertedeitherbyageneralpractitionerorgynaecologistintheupperarmunderlocalanaesthetic.IthasaPearlIndexof0.2whichmakesitoneofthemorereliablereversibleformsofcontraception.ItiseffectiveforthreeyearsandbeingonthePharmaceuticalBenefitsSchemecostsapproximately$34.Amajorreasonfordiscontinuation,however,istroublesomeandprolongedmenstrualbleeding.Somewomenmayalsodevelopfluidretention,weightgainand

headaches.Inthosewomenwhodonotsufferthesesideaffectsitisindeedaverycommendableformofcontraception.Itisparticularlyusefulforthosewomenwhohaveneverbeenpregnantandforthosewhoareforgetfulintakingthecontraceptivepill.

MirenaIntrauterineSystem

Thisdevicehasrevolutionisedcontraceptionandmanagementofheavyperiods.Historicallyintrauterinedeviceswereassociatedwithheavypainfulperiodsandwereinfrequentlyrequestedasaformofcontraception.Theydidhavetheadvantageofalongdurationofactionanddidnotrequireanyspecificactivitytoensuretheircontraceptiveactionincontrasttoothercontraceptivessuchascondomsortheoralcontraceptivepill.Howevertheywerenotpopularbecauseofthetendencytoincreasemenstrualbleedingandperiodpain.TheMirenadevicewasdevelopedinthe1980sandbecamecommerciallyavailableinpartsofEuropein1990andfinallyavailableinAustraliain1999andplacedonthePharmaceuticalBenefitsSchemein2003therebymakingtheseacheap,reliablealternativecontraception.

TheMirenaisimpregnatedwithaprogesteronehormonecalledLevonorgestrel.Ithastwomainbeneficialactions.Firstlyitwillcauseathickeningofcervicalmucoustomakethemucousimpenetrabletopassageofspermandsecondlythereisamarkedthinningoftheendometrium(liningofthewomb)whichresultsinextraordinarilylightmenstrualbleedingwherebyinsomewomenitwillbenonexistentaftertheinitialsixmonths.

ThePearlIndexoftheMirenadeviceis0.3whichisoneofthemoreeffectivereversibleformsofcontraceptionavailable.TheMirenahasafargreaterdegreeofacceptabilitybecauseofthereducedmenstrualbleedingthatisassociatedwithit.TypicallyinthefirstthreemonthsaftertheinsertionofaMirenadevicetherewillbeaprogressivethinningoftheendometriumwhichwillresultinapersistentandsometimestroublesomebrowndischargewhichwillsettledownwithtimeandperseverance.Thisbrowndischargeisalmostuniversallyabsentbysixmonths.Withinthisfirstthreemonthsthevolumeofmenstrualbloodthatislostisequivalentto15%ofwhatithadpreviouslybeen.By12monthsthisvolumeofmenstruallossisgreatlyreducedtojust3%.ItisnotuncommonforwomentoreporthavingverylittleinthewayofanyperiodatallforseveralyearswiththeMirenadeviceinplace.Thisisnotunhealthy.Normalmenstrualbleedingisduetothesheddingofendometriumthathasbecomethickduringanormalmenstrualcycle.Thisthickeningoccursinpreparationforthereceptionofafertilisedeggandifpregnancydoesnotoccurinthatparticularcyclethentheendometriumisshedtogetherwithlossofsomeblood.InthesituationofaMirenadevicebeingpresenttheendometriumissoextraordinarilythinthatthereissimplyverylittleornothingtoshed.Whilethisabsenceofmenstrualbleedingmayconcernsomewomenasasignofundiagnosedpregnancy,mostwomenwillenjoyhavinglessmenstruallossthanbefore.IntheunlikelyeventofpregnancywithaMirenadevicethewomanwillusuallyexperienceothersymptomssuchasbreasttenderness,nausea,changeintasteforcommonthingssuchascoffeeandtoothpaste.Ifanyofthesesymptomsweretooccurthenitwouldbeadvisabletodoahomepregnancytest.

ThetechniqueofinsertionofaMirenadeviceisrelativelystraightforward.Theoptimaltimeforinsertioniswithinthefirstthreedaysofamenstrualperiod.Inthissituationthecervixissofterandslightlydilatedascomparedtoothertimesthroughthemenstrualcycle.Thereisalsotheaddedreassurancethatitishighlyunlikelythatthewomanwillbepregnantatthattime.TherearesomewomenforwhomtheMirenaislessappropriate.Thesearewomenwhohaveneverbeenpregnantandthosethathavenotexperiencedlabour.Inthesesituationsthecervixcanbequitetightandtheinsertiontoopainfultoconductasanoutpatient.IfawomanwouldstillliketoutiliseaMirenadeviceforcontraceptionthenthisprocedurecanbedoneundergeneralanaesthesiainhospital.

Thereareasmallnumberofwomen,approximately1%,whoexperienceexpulsionoftheMirenadevice.ThiscanbedetectedbytheregularcheckingforthepresenceoftheMirenastringonamonthlybasis.Thisisdonebyinsertingafingerintothevaginatodetectthecervix(whichhasthesameconsistencyastheendofyournose)andfeelingforthestring.Itisimportantthatthestringisnotpulledonasthismaydislodgethedevice.Ifthestringisunabletobefeltthenyoushouldattendyourgeneralpractitionerormyselfassoonaspossibleforasimplespeculumexaminationtoseeifthestringispresent.Therearetimeswhenthestringmaycurluponitselfandretractwithintheuterinecavity.ApelvicultrasoundshouldbedoneatthattimetoseewhetherornottheMirenaisstillintheuterinecavity.TheriskofinfectionwithyourMirenadeviceisverylow.Thiscanoccurinthefirst20daysafterinsertionduetothetransgressionofthedevicethroughthethickcervicalmucous.Othersourcesofinfectionincludesexualtransmission.Itisimportantthatthesedevicesbeavoidedinthosepatientswhoarenotinastablesexualrelationshipbutareobviouslyideallysuitedforwomenwhoareinastablerelationship.IntheunlikelyeventofpregnancyoccurringitisimportantthattheMirenadeviceberemovedassoonaspossiblebecauseoftheriskofsepticmiscarriage.

TheMirenadeviceshouldnotinterferewithsexualactivityinanyway.Theperformanceofpapsmearsisunchanged.IftheMirenadeviceprovestobeunsuitableforyouthenitsremovalisusuallyverystraightforwardandpainlessasanoutpatient.

PERMANENTCONTRACEPTION

LaparoscopicSterilisation

Thisprocedureisdoneundergeneralanaesthesiaasdaysurgeryinhospital.Asmallincisionismadewithintheumbilicusandacameraintroducedintotheabdominalcavity.Carbondioxidegasisthenusedtoinflatetheabdomensothataspaceiscreatedthroughwhichotherinstrumentscanbepassedthroughasecondsmallincisionapproximately35cmabovethepubicbone.Throughthisincisionanapplicatorisintroducedandaclipisappliedtoeachtube.Thisclipeffectivelyblocksthefallopiantubesothatspermandeggsareunabletomeet.

Thisshouldbeconsideredasapermanentprocedure.TherearecircumstanceswhereitmaybereversedbutthisrequiresseveralhoursofmicrosurgeryandMedicareandHealthFundsoffernofinancialrebateinthesecircumstances.Itshouldthereforebedoneinthecontextofsomeonewhoisabsolutelycertainthattheirfamilyiscomplete.Itisusefultoconsiderunpleasantscenariossuchasdeathofapartner,divorcefromapartner,disasteroccurringinfamilymemberssuchaschildhoodmalignancyorSuddenInfantDeathSyndrome.Thereisalsoacertaindegreeofregretassociatedwithpermanentformsofcontraceptionandthiswillobviouslyvarywiththeindividualcircumstance.Thelikelihoodoffallingpregnantevenafterthisprocedurehasbeensuccessfulisapproximately1:300duringthefirst10yearsaftertheprocedureisperformed.Thisiscomparabletothepregnancyratefollowinganapparentlysuccessfulvasectomy.

Essure

Thistechniqueinvolvestheplacementofametalandfabricdeviceintothefallopiantubeswheretheyjointheuterinecavity.Itisperformedundergeneralanaesthesiausingatechniquecalledhysteroscopy.Thisiswhereatelescope/cameraispassedthroughthecervicalcanalandthesedevicesintroducedintotheopeningofeachtube.Thisdoesnotrequireanincisionintheabdomen.Followingplacementofthesedevicescontraceptionneedstobecontinuedforthreemonthsuntilanxrayisdonetoconfirmthatthedeviceshavenotmigratedfromtheoriginallocation.Itisduringthesefirstthreemonthsthatthedevicecausesdenseadhesionstooccludethetube.Thisprocedureistotallyandutterlyirreversibleduetotechnicalreasons.Itisalsoassociatedwithasubsequentpregnancyrateofapproximately1:500.Thereisoccasionallytechnicaldifficultieswherebytheopeningofthetubecannotbenegotiatedbythefineinstruments.Thelikelihoodofthisisapproximately2%ofallpatients.

Vasectomy

DrRoperdoesnotperformvasectomy.Informationregardingthiswouldbebestobtainedfromeitheryourgeneralpractitioner,generalsurgeonoraspecialisturologist.Similarprinciplesapply,however,intermsofthecertaintyofamantoundertakethisdecisionowingtoitspermanentnature.Therearecircumstanceswherethisprocedurecanbereversedbutthisisnotalwaysmetwithsuccess.