contraception

• Women of childbearing age are routinely prescribed teratogenic medications.
• Barrier Methods


  • Condoms
  • Female Condoms
  • Cervical Cap
  • Diaphragm
• Condoms


  • Acts as barrier against passage of semen into vagina
  • Good for individuals who have multiple partners
  • Good for individuals who do not want medical intervention for contraception
• Advantages of Condoms


  • Protects against STDs
  • Readily available
  • Inexpensive
  • Allows male partner to be involved in contraception
• Disadvantages of Condoms


  • Failure rate: 2% for perfect use, 15% with typical use
  • Requires responsible attitude on the part of the male
  • May decrease enjoyment of sex
• Female Condoms


  • Polyurethane sheath intended for one-time use with two flexible rings
  • Acts as a barrier to passage of semen into vagina
• Advantages of Female Condoms

  • Protects against STDs
  • Can be inserted up to 8 hrs before intercourse
  • Sheath coated on inside with silicone based lubricant
• Disadvantages of Female Condoms

  • More expensive than condoms
  • Awkward, difficult to place
  • May cause UTI
  • Failure rate: 5% perfect use, 21% typical use
• Cervical Cap


  • Cup-shaped latex device fits over the base of the cervix
  • Spermicide required
  • May be inserted up to 8 hrs prior to intercourse and left in place for 48 hrs

  
• Advantages of Cervical Cap

  • Provides continuous protection for duration of use regardless of number of acts of intercourse
  • Does not require additional spermicide
  • Non-hormonal
• Disadvantages of Cervical Cap

  • Requires professional fitting and training
  • Can lead to cervical erosions
  • Obesity can make placement difficult
  • High failure rate (6% with perfect use, 16% with typical use in nulliparous women; 26% with perfect use, 32% with typical use in parous women)
  • Risk of toxic shock syndrome if left in place longer than prescribed period
  • Requires normal pap smears
• Diaphragms


  • Shallow cap with spring mechanism in rim to hold in place in vagina
  • Spermicide required
  • Must be left in place 6 hrs following intercourse

  
• Advantages of Diaphragms


  • Non-hormonal contraception controlled by woman
• Disadvantages of Diaphragms


  • High failure rate: perfect use 6%, typical use 16%
  • Prolonged use can increase risk of UTIs
  • Requires professional fitting and training
  • Can develop odor if not properly cleaned
  • Can cause vaginal erosions
  • Requires additional spermicide for repeated use
• Types of Oral Contraceptive Pills

  • Combined Oral Contraceptive Pills
  • Extended-cycle/continuous Oral Contraceptive Pills
  • Progestin-Only Contraceptive Pills
  • Emergency Contraception
• Combined Oral Contraceptive Pills

  • Contain oestrogen and progesterone
  • Monophasic
  • Multiphasic
  • Block ovulation, alter cervical mucus, stimulate atrophic change in endometrium
  • 21 days of hormone followed by 7 days of placebo to allow withdrawal bleeding
• Advantages of Combined Oral Contraceptive Pills

  • Failure rate less than 0.3% with perfect use (8% typical use)
  • Fertility returns rapidly
  • Bleeding is decreased
  • Greater cycle predictability
  • Decreased risk of benign breast disease, PID, ovarian and endometrial cancers
• Disadvantages of Combined Oral Contraceptive Pills

  • Increased risk of stroke, acute MI, venous thromboembolic disease
  • Increased risk of hepatic adenoma, cervical cancer, breast cancer
  • Do not protect against STDs
  • When used with antibiotics or anticonvulsants, efficacy may be decreased
• Side effects of Combined OCPs

  • Nausea
  • Headache
  • Weight gain
  • Vomiting
  • Dizziness
  • Mastalgia
  • Melasma
  • Hypertension
  • Mood changes
  • Decreased libido
  • Increased triglycerides
  • Severe depression
  • Spotting, breakthrough bleeding
• Contraindications of Combined OCPs

  • Smoker of age > 35
  • History of breast cancer
  • Abnormal vaginal bleeding of unknown etiology
  • Cerebrovascular disease
  • Congenital hyperlipidemia
  • Ischemic heart disease
  • Migraine
  • Active viral hepatitis
  • Diabetes >20 years OR with severe vascular disease, nephropathy, retinopathy, neuropathy
  • Major surgery with prolonged immobilization
  • Severe hypertension
  • Hepatic neoplasm
  • Impaired liver function
  • Thrombophlebitis, thromboembolic disease, known thrombogenic mutations
• Progesterone-Only OCPs


  • Suppresses ovulation, has variable dampening effect on midcycle peaks of LH and FSH, increases cervical mucus viscosity, leads to atrophic endometrium, reduces cilia motility in the fallopian tube
• Advantages of Progesterone-Only OCPs


  • Risk of serious complications to which oestrogen contributes is greatly reduced
  • Decreased dysmenorrhea, menstrual blood loss, PMS symptoms
  • Fertility returns immediately after cessation
• Disadvantages of Progesterone-Only OCPs

  • Requires compliance
  • Does not protect against STDs
• Side effects of Progesterone-Only OCPs


  • Menstrual irregularities
  • Spotting
  • Breakthrough bleeding
  • Amenorrhea
  • Weight gain
  • Headache
  • Adverse impact on lipids
  • Mood changes
  • Severe depression
  • Acne
  • Hypoestrogenism
  • Hair loss
• Contraindications of Progesterone-Only OCPs


  • Pregnancy
  • Current breast cancer
  • Vaginal bleeding
• Caution for Progesterone-Only OCPs

  • Breastfeeding < 6 weeks postpartum
  • Active viral hepatitis
  • Hypertension >160/100
  • Current ischemic heart disease
  • Stroke
  • Current DVT or pulmonary embolism
  • Diabetes with vascular disease
  • Cirrhosis
• Progesterone-Only OCPs


  • Ovrette (0.075 mg Norgestrel)
  • Micronor or Nor-QD (0.35 mg norethindrone)
• Emergency Contraception


  • Progestin-only: Plan B (levonorgestrel 0.75 mg)
  • Norgestrel 1.5 mg
  • Combined: Norgestrel 100 mg, ethinyl estradiol 100 mcg
  • Levonorgestrel 50 mg, ethinyl estradiol 100 mcg
• Emergency Contraception Timing


  • First dose < 72 hours after unprotected intercourse, second dose 12 hours later
• Injectable Contraceptives


  • Depo-Provera
• Injectable Contraceptives (Depo-Provera)


  • Progesterone-only: Depo-medroxyprogesterone acetate (DMPA) 150 mg IM every 12 weeks
  • Alters endometrial lining, thickens cervical mucus and blocks LH surge preventing ovulation
• Advantages of Depo-Provera


  • Extremely effective. Failure rate 0.3% with perfect use, 3% with typical use
  • Efficacy is not altered by varying weight nor use of concurrent medications nor sickness/diarrhea
  • Decreased anemia, dysmenorrhea
  • Decreased risk of endometrial and ovarian cancer, PID, ectopics
  • Safe for use in breast-feeding mothers
  • Does not produce serious side effects of oestrogen
• Disadvantages of Depo-Provera


  • Involves injections and remembering to visit Dr every 3 months
  • Persistent irregular bleeding
  • Delayed return to fertility
  • Weight gain-about 5 lbs in first year
  • Depression
• Side effects of Depo-Provera

  • Oedema
  • Thromboembolic disorders
  • Nausea
  • Vomiting
  • Diarrhea
  • Abdominal pain
  • Hot flashes
  • Decreased libido
  • Menstrual changes
  • Breast tenderness
  • Weight gain
  • Headache
  • Insomnia
  • Dizziness
  • Depression
  • Fatigue
  • Nervousness
  • Rashes
  • Alopecia
  • Acne
  • Injection site reactions
  • Can cause decreased bone mineral density, but this is not associated with increased fracture risk, is transient and reversible upon discontinuation
• Contraindications to Depo-Provera


  • Known or suspected pregnancy
  • Undiagnosed vaginal bleeding or missed abortion
  • Known or suspected malignancy of the breast
  • Active thrombophlebitis
  • Current thromboembolic disease
  • Cerebral vascular disease
  • Liver dysfunction or disease
• Progestogen Contraceptive Implants


  • Provide effective, convenient, long-term contraception, quickly reversible
  • Implanon® marketed in Australia May 2001- 350,000 devices inserted since introduction- PBS listed
  • Main problems- deep insertions, irregular bleeding in users
  • Follicular levels of oestradiol maintained- no concerns re bone mass
• Contraceptive Patch


  • Ortho Evra
• Ortho Evra


  • Apply once weekly for 3 weeks
  • Placebo is one patch-free week during which withdrawal bleeding occurs
  • Blocks LH surge (preventing ovulation), thickens cervical mucus, alters endometrial lining
• Advantages of Ortho Evra

  • Efficacy similar to OCPs: 0.3% failure rate with perfect use, 8% with typical use
  • Once a week regimen may be easier for some patients to follow compared to daily pill
  • Less effective in women who weigh > 90 kg
• Disadvantages of Ortho Evra


  • Side effects, contraindications, cardiovascular risk similar to combined OCPs
  • May also have application site reactions
  • 1-2 patches per year per user may fall off