CONTRACEPTION

contraception

historical and social perspectives

sharing responsibility & choosing a method

hormone-based contraceptives

barrier methods

intrauterine devices

emergency contraception

fertility awareness methods

sterilization

less-than-effective methods

new directions in contraception

1870s – Comstock laws

dissemination of contraceptive information through U.S. mail prohibited (as obscene)

1915 – Margaret Sanger opened an illegal clinic

where women could obtain and learn to use diaphragms she had shipped from Europe

[picture of Margaret Sanger talking to other women]

Margaret Sanger and her sister in court in 1916

after police arrested her and closed her first birth control clinic

she was arrested 8x

preachers called her a “lascivious monster” bent on murdering unborn children

[picture of Margaret and her sister in court]

July 1912 Nurse Sanger visited a cramped flat in New York.

Sadie Sachs, 28, a mother of three, was near death as a result of a self-induced abortion.

She pleaded with Nurse Sanger and the doctor:

“Another baby will finish me. What can I do to prevent it?”

The doctor’s gruff reply: “Tell Jake to sleep on the roof.”

Three months later, Sadie Sachs was dead - of another self-induced abortion.

Margaret Sanger had a cause.

1960 – The first birth control pills came on the U.S. market.

[picture of women in line waiting to receive pills]

U.S. Supreme Court: (1965)

Griswold v. Connecticut, 381 U.S. 479

Griswold was convicted as an accessory for giving married persons

information and medical advice on how to prevent conception

and for prescribing a contraceptive device for the wife’s use

she was fined $100 (she could have been jailed for a year)

[pictures of Estelle Griswold]

U.S. Supreme Court:

Eisenstadt v. Baird, 405 U.S. 438 (1972)

William Baird was convicted of giving a single woman a contraceptive foam

at the close of a lecture to Boston University students

William Baird was sentenced to three months in the Charles street jail (a dungeon built in 1851).

His case took 5 years & 6 court cases before he won in the Supreme Court.

[picture of Bill Baird]

reasons for couples to use contraception

establish their relationship with each other first

establish financial stability first

establish career first

space the pregnancies improving maternal and child health

limit the size of their family

avoid bearing children with hereditary diseases or birth defects

reduce the problem of overpopulation

reduce the devastation of the AIDS epidemic

optimum spacing of pregnancies

1970 Study in UK:

13% of babies with dangerously low birth weight or death soon after birth

could be accounted for by a pregnancy too close after the previous one.

The classic 2-year age gap between children was associated with the healthiest outcome for each baby.

1981 WHO study (Australia / Hawaii / Pakistan / Egypt / Saudi Arabia):

There was increased risk to the health of a second or subsequent baby

when the interval between pregnancies was less than 1 year.

US survey of 1 million births:

3-fold increase in risk for a baby born with a low birth weight

if it was conceived 3 months after the previous birth compared to 2 years later

optimum spacing of pregnancies

Pakistan Survey:

60% of pregnancies conceived within a year of the last one ended in miscarriage

Turkey Study:

37% of pregnancies conceived less than 4 months after the last pregnancy were lost

Method Failure Rate* If Typical Number* .

Used Correctly Who Become .

And Consistently Pregnant Accidentally

No Method 85 85

Estrogen-progestin pills 0.3 8

Condoms (male) 3 16

Fertility awareness 9 20

*Number of women out of 100 who become pregnant by the end of the first year of using a particular method.

Backup Method: Using a second contraceptive method simultaneously with a first improves the odds of preventing pregnancy.

“OUTERCOURSE”

noncoital forms of sexual intimacy

includes kissing, touching, petting, mutual masturbation, oral and anal sex

effective at preventing pregnancy provided the male does not ejaculate near the vaginal opening

does not eliminate chances of spreading STDs

oral contraceptives (“the pill”)

are the reversible method of birth control

most commonly used by U.S. women

including college age women

[pictures of contraceptive pills]

“the Pill” - 4 basic types:

constant-dose combination pills

Seasonale

multiphasic pills (triphasic)

progestin-only pills

[pictures of contraceptive pills]

constant-dose combination pills - birth control pills that

contain a constant daily dose of estrogen and progestin

Example: Ortho-Novum 1/35

0000000 1mg norithendrone plus 0.035mg ethinyl estradiol

ooooooo no hormones (placebo pills)

Seasonale – birth control pills that contain a constant daily dose

of estrogen and progestin to be taken for 3 months

0000000 0000000 0000000 – 0.15mg levonorgestrel and 0.03mg ethinyl estradiol

ooooooo – no hormones (placebo pills)

multiphasic pills – birth control pills that vary the dosages

of estrogen and progestin during the cycle

Example: Ortho-Novum 7/7/7 (triphasic)

0000000 – 0.5mg norethindrone plus 0.035mg ethinyl estradiol

XXXXXXX – 0.75mg norethindrone plus 0.035mg ethinyl estradiol

ooooooo – 1mg norethindrone plus 0.035mg ethinyl estradiol

******* -- no hormones (placebo pills

progestin-only pills – contraceptive pills that

contain a small dose of progestin and no estrogen

Example: Ovrette

0000000 – 0.075mg norgestrel

how oral contraceptives work

= how estrogen works

= how progesterone works

estrogen

affects hypothalamus

inhibits release of LH and FSH

inhibits ovulation

[picture of biological events of menstrual cycle]

progestin

thickens and chemically alters the cervical mucus

so that it hampers the passage of sperm into the uterus

[picture of location in uterus where mucus could hamper sperm entry]

progestin

changes the lining of the uterus

making it less receptive to implantation by a fertilized egg

[picture of biological events of menstrual cycle]

progestin

may inhibit ovulation

by mildly disturbing hypothalamic, pituitary, and ovarian function

[picture of biological events of menstrual cycle]

COCs Mechanism of Action: Ovulation Suppression

Normal Menstrual Cycle

[picture of follicle size changes

picture of LH & FSH blood level changes

picture of estrogen & progesterone blood level changes]

Cycle Modified by COCs

[picture of follicle size staying the same

picture of LH & FSH blood level not changing much

picture of estrogen & progesterone blood level not changing much]

COCs Mechanism of Action: Mucus and Endometrial Changes

Normal Menstrual Cycle

[picture of follicle size changes

picture mucus changes

picture of endometrial thickness changes]

Cycle Modified by COCs

[picture of follicle size staying the same

picture of mucus not changing much

picture of endometrial thickness not changing much]

Contraceptive Technology Update (CTU)

MAQ Exchange

U.S. Agency for International Development (USAID)

Office of Population and Reproductive Health

Maximizing Access and Quality Initiative (MAQ)

pill users should take the pill at the same time every day to maximize effectiveness

missing one or more pills can lower hormone levels and allow ovulation to occur

vomiting and diarrhea may mean that the pill does not get absorbed adequately

other medications can interfere with the effectiveness of OCPs:

Barbiturates, Ampicillin, Tetracycline, Antihistamines, Tegretol, Dilantin, Rifampin, Phenylbutazone

if you have any questions – use a backup method!

advantages of oral contraceptives

often eliminates Mittelschmerz

reduces menstrual cramps

reduces the amount and duration of flow

may diminish premenstrual tension symptoms

helps relieve endometriosis

may decrease benign breast disease

decreases risk of endometrial and ovarian cancer

may enlarge breasts

may decrease acne

COCs Provide Endometrial Cancer Protection

COCs reduce risk by more than 50%

Protection develops after 12 months of use and lasts for at least 15 years

Lifetime risk of acquiring endometrial cancer

Number per 100 women

United States

xxxxxxxxxxxx 3.1 Non COC user

xxxx 1.2 COC users (8+ years of use)

Costa Rica

xxx 0.7 Non COC user

x 0.3 COC users (8+ years of use)

China

xx 0.4 Non COC user

x 0.1 COC users (8+ years of use)

COCs Provide Ovarian Cancer Protection

COCs reduce risk by more than 50%

Protection develops after 12 months of use and lasts for at least 15 years

Lifetime risk of acquiring ovarian cancer

Number per 100 women

United States

xxxxxxx 1.7 Non COC user

xxx 0.7 COC users (8+ years of use)

Costa Rica

xx 0.6 Non COC user

x 0.2 COC users (8+ years of use)

China

xx 0.6 Non COC user

x 0.2 COC users (8+ years of use)

disadvantages of oral contraceptives

does not protect against AIDS and other STDs

serious problems may occur: gallbladder disease, liver tumors,

blood clots (in lungs, in legs, or elsewhere), strokes, heart attacks, migraine headaches

depression may increase or decrease

irregular and “break-through” bleeding may occur

side effects such as nausea, fluid retention, increased appetite, acne may occur

[picture of contraceptive pills]

COC Use and Estimated Annual Mortality Rates of CVD

[bar graph showing highest risk for older women who smoke and use COCs]

COC = Combined Oral Contraceptives

RISKS OF ORAL CONTRACEPTIVE USE

risk in OC users compared to nonusers

data from Lunelle Prescribing guide provided by PHARMACIA

Heart Attack 2x-6x

1^st episode superficial thrombosis 3x

Deep vein thrombosis or pulmonary embolism 4-11x

Thrombotic stroke

Normotensive 3x

Severe hypertension 14x

Hemorrhagic stroke

Nonsmoker + OCP 1.2x

Smoker – OCP 2.6x

Smoker + OCP 7.6x

Normotensive 1.8x

Severe hypertension 25.7x

RISKS OF ORAL CONTRACEPTIVE USE

risk in OC users compared to nonusers

data from Lunelle Prescribing guide provided by PHARMACIA

DMPA and breast cancer 1.1 – 2.2x

Benign hepatic adenoma 3.3 cases / 100,000 cases

(attributable risk)

Hepatocellular carcinoma <1 / million users

(attributable risk)

Number of deaths per year per 100,000 non-sterile women

Adapted from Ory HW 1983 as printed in Lunelle Prescribing guide provided by PHARMACIA

Method 20-24 25-29 35-39 40-44 .

None 7.4 9.1 25.7 28.2 birth-related deaths

OCP 0.5 0.9 13.8 31.6 method-related deaths

Nonsmoker

OCP 3.4 6.6 51.1 117.2 method-related deaths

Smoker

Condom 1.6 0.7 0.3 0.4 birth-related deaths

Diaphragm 1.2 1.2 2.2 2.8 birth-related deaths

Contraceptive Technology

reference book for:

physicians, nurses, midwives, counselors, administrators, students

Dr. Karen Trewinnard,

B.M., M.F.F.P.,

worked as a doctor for 20 years

specializes in fertility awareness

runs a preconception planning clinic in Portsmouth, England.

Fertility & Conception

[pictures of book covers]

voluntary risks in perspective

activity_________________chance of death / year

motorcycling 1 in 1,000

automobile driving 1 in 6,000

using tampons 1 in 350,000

having intercourse (PID) 1 in 50,000

nonsmoker using OCPs 1 in 63,000

smoker using OCPs 1 in 16,000

laparoscopic tubal ligation 1 in 67,000

vasectomy 1 in 300,000

continuing pregnancy 1 in 14,300

illegal abortion 1 in 3,000

legal abortion <9 wks 1 in 500,000

legal abortion 9-12 wks 1 in 67,000

legal abortion 13-15 wks 1 in 23,000

legal abortion >15 wks 1 in 8,700

C.T. p. 146

ESTROGEN SIDE EFFECTS

nausea

breast tenderness

increased breast size (ductal and fatty tissue)

fluid retention & cyclic weight

leukorrhea (whitish discharge from vagina & uterus)

cervical extrophia (endocervical lining extends to outer cervix)

headaches

thromboembolic complications (traveling blood clots)

pulmonary emboli (blood clots in lung vasculature)

hepatocellular adenomas (non-cancerous liver tumors)

hepatocellular cancer (liver cancer)

growth of leiomyomata (non-cancerous uterine tumors)

telangiectasia (spidery looking blood vessels: skin etc)

PROGESTIN SIDE EFFECTS

increased appetite & weight gain

depression, fatigue, tiredness

decreased libido and enjoyment of intercourse

acne, oily skin

headaches

increased breast size (alveolar tissue)

increased LDL cholesterol levels (“bad cholesterol”)

decreased HDL cholesterol levels (“good cholesterol”)

diabetogenic effect (producing diabetes)

decreased carbohydrate tolerance

pruritis (itching)

(note based on other sources: may decrease bone mineral density)

both ESTROGEN and PROGESTIN contribute to:

headaches

hypertension

(high blood pressure)

myocardial infarction

(heart attack)

cervical dysplasia

(abnormal changes in the cervical cells)

ORAL CONTRACEPTIVES

Progestin(mg) Estrogen (mcg)

Combination Loestrin 1/20 1 20

Monophasic Ortho-Novum 1/35 1 35

Lo/Ovral 0.3 30

Demulen 1/50 1 50

Combination Ortho-Novum 10/11 0.5/1 35

Biphasic Mircette 0.15/0 20/10

Combination Orto-Novum 7/7/7 0.5/0.75/1 35

Triphasic Triphasil 0.05/0.075/0.125 30/40/30

Combination Estrostep Fe 1 20/30/35

Estrophasic

Progestin Micronor 0.35 0

Only Ovrette 0.075 0

Seasonale

FDA approved – became available Oct 2003

84 active pills in a row

7 placebos

result: 4 periods / year

side effects:

breast tenderness

blood clots

breakthrough bleeding

(7.5% quit because of this

compared to 1.8% on conventional pill)

method failure rate

best typical

estrogen-progestin 0.3 8 $384 - $516 /y*

pills (incl. Seasonale) ($32 - $43 /cycle)

progestin-only 0.3 8 $384 - $456 /y*

pills ($32 - $38 /cycle)

*1 year with 100 occurrences of intercourse

self reported missed pills

50% forget 1 or more pills / cycle

22% forget 2 or more pills / cycle

electronically tracked pills

50% missed 3 or more pills / cycle

disposable ring inserted on or about day 5 of the menstrual cycle and worn continuously for 3 weeks.

failure rate as good or better than oral contraceptives.

Website:

www.nuvaring.com

[picture of Nuvaring]

OrthoEvra

application sites: buttocks, abdomen, torso (excluding breasts), upper outer arm

adhesion data:

<2% of patches fell off

<3% of patches partially lifted

[picture of woman wearing patch]

Patch: Ethinyl Estradiol-Norelgestromin: 0.02mg-0.150mg/24hrs

apply patch to clean, dry, intact skin

on buttock, abdomen, upper arm or upper torso

start on first day of menses or first Sunday after menses begins

a new patch is applied each week on the same day for 3 weeks (21 total days)

week four is patch free

[picture of Ortho Evra product]

five of the fifteen pregnancies reported with Ortho Evra

were among women with a baseline body weight > or = 198 lbs (90kg)

suggesting that the patch may be less effective in these women

[picture of Ortho Evra product]

method failure rate

best typical

vaginal ring 0.3 8 $580 /y*

Nuvaring

skin patch 0.3 8 $420 /y*

Ortho Evra

*1 year with 100 occurrences of intercourse

Norplant - 6 capsules implanted in a woman’s arm

release progestin over a 5 year period

disadvantages: no protection from STDs,

side effects (such as menstrual irregularity, cramps, headaches, weight gain, nausea)

may have difficult and painful removals with possible scarring and permanent nerve damage

[picture of Norplant insertion procedure]

according to a 1993 study

19% of removals took > 1 hour

6% of removals required > 1 visit

¼ of patients reported significant pain during removal

lawsuits exceeded 50,000

NORPLANT no longer available:

Aug 2000 – Wyeth suspended shipment of Norplant kits

method best failure rate typical failure rate

over 1 year period over 1 year period

Norplant 0.05 0.05

http://www.implanon-usa.com/en/consumer/index.asp

[picture of IMPLANON product]

lasts up to 3 years

failure rate <1

injected contraceptives

Depo-Provera = medroxyprogesterone acetate (a progestin)

frequency of shots

Depo-Provera: every 12 weeks

resumption of fertility after stopping:

Depo-Provera: 10 months

advantages

don’t need to remember to take a pill

no-one else (besides health care practitioner) knows

disadvantages

no protection against STDs,

side effects: menstrual irregularities,

weight gain, headaches, breast tenderness,

dizziness, mood changes

reduced bone mineral density

method failure rate

best typical

Depo-Provera 0.3 0.3 $196 /y*

injection ($70 /injection)

*1 year with 100 occurrences of intercourse

contraceptives and bleeding patterns

Am I healthy? Am I pregnant? Am I menopausal?

Where is all the blood going?

Depo-Provera

within 2 years 80% will be amenorrheic

some women have longer / heavier periods;

or spotting & breakthrough bleeding

condom

sheath that covers penis

protects against

unwanted pregnancy

sexually transmitted diseases

lubrication

decreases condom breakage

enhances penile sensitivity

[picture of condoms]

some sexually transmitted diseases including the AIDS virus

can pass through pores in natural-membrane condoms

but not through smaller pores in latex or polyurethane condoms

average shelf life: 5 years

do not store in hot places!

[picture of condoms]

correct use

unroll the condom over the erect penis

before any contact between penis and vulva occurs

[picture of unrolling procedure]

with plain-end condoms twist the end of the condom

before rolling the condom down over the penis to

create a reservoir

[picture of procedure for creating a reservoir]

hold condom at base of penis before withdrawing

[picture of condoms]

if the condom is not lubricated use vaginal secretion, saliva,

or water-based lubricant

to put on the vulva and outside the condom before insertion

to minimize chance of breakage

do not use oil-based lubricants

such as baby oil, vaseline, massage oil, vegetable oil, hand-lotions etc.

[picture of condoms]

disadvantages

can interrupt spontaneity

can reduce penile sensitivity

some men unable to maintain erection while putting on condom

some people allergic to latex condoms

condoms may have pin-hole size leaks

condoms may break or slip off

[picture of condoms]

major advantage

condoms greatly decrease the risk of STDs including AIDS

spermicide nonoxynol-9

may provide better protection against pregnancy????

does not enhance protection against AIDS

(might even make things worse!?)

[picture of condoms]

method failure rate

best typical

male condom 3 16 $100 /y*

($1 /condom)

*1 year with 100 occurrences of intercourse

study group condom breaks / acts of intercourse

*reproductive employees 1:161

university students 1:92

women at Family Planning Clinic 1:16

*reproductive employees

= individuals working in family planning,

reproductive health, gynecology and obstetrics

from Contraceptive Technology p169

medications causing latex degeneration

Monistat, Estrace, Premarin, and Femstat vaginal cream, Vagisil ointment

if you are using these products, abstain from sex or use another (non-latex containing) contraceptive method

heterosexual transmission

among partners of HIV-positive individuals

couples having sexual activity without condoms

82% of spouses became HIV-positive

couples having sexual activity using condoms

17% of spouses became HIV-positive

(some couples reported condom breakage, improper use, and fellatio)

the female condom

can be inserted prior to sexual activity

does not need to be removed immediately following ejaculation

sex is less messy

some women have difficulty inserting

there may be decreased sensations

[picture of female condom insertion technique]

method failure rate

best typical

female condom 5 21 $300 /y*

($3 /condom)

*1 year with 100 occurrences of intercourse

diaphragm

must be fitted by a skilled practitioner

[picture of diaphragm insertion]

place one teaspoon spermicidal jelly into cup

use the finger to also spread some around edge

insert diaphragm jelly side up

check placement to make certain cervix is covered

[picture of diaphragm insertion]

the diaphragm should remain in the vagina

for at least 6-8 hours following intercourse

to avoid TSS don’t leave it in for longer than needed

if repeated intercourse occurs within short time frame

leave diaphragm in place but add more jelly

[picture of diaphragm insertion]

care of the diaphragm

with good care it can last several years

check periodically for defects

(hold up to light, fill with water)

after removal wash with mild soap and warm water

carefully and thoroughly dry it

if needed dust with cornstarch but not with talc!

do not use oil-based lubricants (latex deteriorates)

[picture of diaphragm insertion]

diaphragm benefits and drawbacks

may decrease vaginal infections

reduces risk of precancerous changes in cervical cells

high failure rate

woman or partner may have latex allergy

some women may have bladder discomfort, urethral

irritation, or recurrent cystitis

[picture of diaphragm insertion]

types of diaphragms

[pictures of arcing spring, coil spring, wide seal rim, and flat spring diaphragms]

method failure rate

best typical

diaphragm 6 18 $50 /diaphragm

$280 /fitting

$85 /spermicide*

*1 year with 100 occurrences of intercourse

cervical cap

needs to be fitted by a skilled practitioner

can be inserted up to six hours before intercourse

should not be removed for at least 6-8 hours after intercourse

do not leave in longer than 24 hours (risk of TSS)

wash with warm water and soap after removal

do not use oil-based lubricants

[picture of cervical cap]

advantages compared to diaphragm

does not require pelvic structure support

requires less spermicide than diaphragm

disadvantages compared to diaphragm

women with distortions of cervix cannot use

more difficult to learn to use

may be uncomfortable for some women

may dislodge during intercourse

[picture of cervical cap]

[pictures of cervical cap and diaphragm

comparing and contrasting how they stay in place

diaphragm wedges against pubic bone, cervical cap doesn’t]

method failure rate

best typical

cervical cap 9 18 $50 /cap

(woman has never been pregnant) $280 /fitting

$85 /spermicide*

cervical cap 26 40

(woman has been pregnant)

*1 year with 100 occurrences of intercourse

spermicides

foam, suppositories, creams, jellies, film

suppositories take time to dissolve and spread (20min)

another application is necessary

before each additional act of intercourse

wait 8 hours after intercourse before douche (or bath?)

[pictures of spermicidal products]

additional lubrication may be helpful or nuisance

irritation of genital tissues may occur

may increase yeast infections and urinary tract infections

suppositories may feel gritty if partly dissolved

taste and scent may be disagreeable

insertion may interrupt spontaneity (for 30 seconds +)

[pictures of spermicidal products]

method failure rate

best typical

spermicides 6 30 $85*

(85 cents/application)

*1 year with 100 occurrences of intercourse

Is it safe to swallow spermicides during sex?

the FDA noted in 1980

that spermicides are regularly swallowed during oral sex

because of their extremely low toxicity

and because nonoxynol-9 is used as a wetting agent in foods,

the FDA deemed spermicides safe when swallowed in small quantities.

Adult Industry Medical Health Care Foundation

http://aim-med.org/10nonoxynol.html

Accessed 3/14/02

use of a dam to prevent ingestion during oral sex

don’t swallow semen or vaginal fluids or have oral sex without using a condom or dam

(a latex sheet that covers the vaginal area during oral sex)

especially if you have sores or cuts in your mouth

many pharmacies now carry dams on racks next to condoms

if you’re fresh out of Saran Wrap and having trouble with the raw taste of latex

put a little honey or jam on your side of the dam

don’t forget to lavish your lube on the sweet flesh on the other side

nonoxynol-9 and HIV transmission

nonoxynol-9 kills HIV in a test tube

use of nonoxynol-9 has not been proven to decrease HIV transmission during human sexual intercourse

there is now evidence that nonoxynol-9 may even facilitate HIV transmission

from 1996 until May 2000

UNAIDS (United Nations Programme on AIDS)

sponsored a study of the effectiveness of a gel

which contained 52.5 milligrams of N-9

(called COL-1492 in the trial and advantage-S in the United States)

compared to an inactive placebo gel

the study was conducted in several locations in Africa

study enrolled nearly1,000 HIV-negative commercial sex workers

all participants advised to use condoms consistently and correctly

half of the women were provided a placebo gel

half of the women received an N-9 gel

none of the women, or the researchers, knew which product each woman received

women who used N-9 gel became infected with HIV at about a 50% higher rate

than women who used the placebo gel

women who used N-9 also had more vaginal lesions

which might have facilitated HIV transmission

in a small scale study in New York city lubes containing N-9

stripped away much of the protective rectal lining

in all four study participants

– something that took hours to heal –

but the lining remained intact with the placebos

contraceptive sponge

effective for repeated acts of intercourse without needing additional spermicide

no prescription (or fitting process) needed

[picture of contraceptive sponges]

method failure rate

best typical

sponge 9 20 (13-16) $200*

(woman has never been pregnant) ($2 /sponge)

sponge 20 40

(woman has been pregnant) (10 according to

Today sponge

manufacturer)

*1 year with 100 occurrences of intercourse

What happened to the Today® Contraceptive Sponge?

Production of the Sponge ceased March 1994 after the FDA inspected the Whitehall-Robins Healthcare plant where it was manufactured.

The inspection revealed “bacterial contamination of the water used to make the Today® Sponge as well as other products manufactured in the facility, including nasal sprays, ointments and suppositories.”

[picture of Seinfeld character Elaine contemplating whether a potential partner is sponge-worthy]

April 22, 2005

the Today® Sponge

has won re-approval for marketing from the FDA

Press Release

http://www.todaysponge.com

IntraUterine Devices (IUDs)

Copper-T (ParaGard) copper wire wrapping

alters tubal and uterine fluids affecting sperm and egg so fertilization does not occur

(effect lasts 10 years)

Progestasert T (plastic T releasing progesterone)

thickens cervical mucus, alters endometrial lining, impairs tubal motility, disrupts ovulatory patterns

(effect lasts 1 year)

[picture of IUDs]

Mirena – contains & releases hormone – levonorgestrel

(a progestin hormone often used in birth control pills)

(effect lasts 5 years)

FDA – approved Dec. 2000

after being available in Europe for 10 years already

and having been used by approximately 2 million women worldwide

[picture of Mirena]

Mirena works precisely where you need it.

thinning of the lining of the uterus

inhibition of sperm movement

thickening of the cervical mucus

[picture of Mirena in place]

Changes in the uterine lining (endometrium) during the normal menstrual cycle

[picture of uterine lining becoming very thick around the time of ovulation]

Uterine lining (endometrium) in “resting state” with Mirena

[picture of uterine lining never becoming very thick]

Who can use an IUD?

women in stable monogamous relationships

no history of sexually transmitted diseases or PID

have at least one child or have completed childbearing

25 years of age or older

ready access to medical facilities

What does ongoing use require?

woman or partner must check each month after her period

to see that the string is the same length as when the IUD was inserted

[pictures of IUDs]

advantages

convenient (nothing to remember or buy)

allows uninterrupted sexual interaction

developed in 1960s

nearly 10% of US women used them 1970s

1980s decrease in popularity

because of reports of PID & infertility

2,000,000 users 1982

310,000 users 1995

[pictures of IUDs]

disadvantages

increased risk of Pelvic Inflammatory Disease (PID) ?????

increased risk of infertility ?????

discomfort, cramping, bleeding, or pain may occur

during insertion and sometimes afterwards

2-20% of users expel IUD within first year after insertion

rarely IUD can break through uterine wall (1-9/1000)

if pregnancy occurs in spite of IUD

50% chance of miscarriage

5% chance of ectopic pregnancy

[pictures of IUDs]

outside the 20 days following insertion

STD risk not increased according to one study

no association between copper IUD use & tubal infertility

large study of Mexican nulligravid women

chances of expulsion higher in nulliparous women

[pictures of IUDs]

[pictures of IUD insertion technique]

[pictures of IUD falling out through cervix and IUD perforating through uterine wall]

[pictures of perforating IUD from user blog]

IUD types

[pictures of:

Saf-T-Coil 1967-1983

Copper-7 1973-1986

Lippes Loop 1964-1985

Copper-T 380 1984

Progestasert 1976

Copper-T 1976-1986

Dalkon Shield 1970-1975]

the Dalkon shield with its multifilament tail

was the primary culprit responsible for complications

litigation fallout made most manufacturers withdraw products

[pictures of various types of IUDs]

[pictures of various brands of IUD in table below]

Paragard Mirena Skyla Liletta Kyleena

1984 2001 2013 2015 2016

10 years 5 years 3 years 3 years 5 years

32mm 32mm 28mm 32mm 28mm

36mm 32mm 30mm 32mm 30mm

0 levonorgestrel 52mg 13.5mg 52mg 19.5mg

approved for women who were done having children----------------------- approved for

all women

method failure rate

best typical

Progestasert-T IUD 1.5 % 2 % $500*

1 year protection

ParaGard T 380A 0.6 % 0.8 % $550

10 years protection ($55* if used 10y)

Mirena 0.1% 0.1% $700

levonorgestrel-releasing ($140* if used 5y)

5 years protection

*1 year with 100 occurrences of intercourse

PID risks

gonococcal infection/coital act

infected male -> uninfected female 50%

infected female -> uninfected male 25%

PID per woman with cervical gonorrhea

40% if not treated

0% if adequately treated

infertility per PID episode

1st episode 11%

2nd episode 23%

3rd episode 54%

Risk of PID is Highest in First Month After IUD Insertion

[bar graph showing PID Rate vs. Time Since Insertion]

emergency contraception

prevents a pregnancy after unprotected intercourse

risk of pregnancy from unprotected mid-cycle intercourse is 20-30%

reasons for emergency contraception

condom broke or diaphragm slipped

unplanned sex (failure to use contraception)

sexual assault

emergency contraception could prevent 2.3 million unintended pregnancies/year in US

emergency contraception usually needed on the weekend when the doctor’s office is closed

emergency contraception

Emergency Contraceptive Pills (ECPs) are taken in two doses

1^st dose within 72 hours of unprotected intercourse

2^nd dose 12 hours after 1^st dose

11 brands of pills that can be used as ECPs in the US

each Pill Brand is followed by the number of pills for 1 dose

Alesse® 5 pink pills

Levlen® 4 light orange pills

Levlite® 5 pink pills

Levora® 4 white pills

Lo/Ovral® 4 white pills

LowOgestrel® 4 white pills

Nordette® 4 light orange pills

Ogestrel® 2 white pills

Ovral® 2 white pills

Tri-Levlen® 4 yellow pills

Triphasil® 4 yellow pills

Trivora® 4 pink pills

the Preven® Emergency Contraceptive Kit

produced by Gynetics, Inc., contains

Yuzpe regimen ECPs (two pills per dose)

A pregnancy test

Instructions for use

it was approved by the FDA and was the first product

specifically labeled and marketed for emergency contraception

a second emergency contraceptive product

subsequently came onto the market

called “Plan B”

Preven

nausea 42%

vomiting 16%

recommendation: take meclizine HCl

(Antivert, Antrizine, Bonine etc.)

25mg, 1 hour before contraceptive dose

Plan B

less nausea & vomiting

types of emergency contraception

Progestin – containing pills

Plan B One-Step, Next Choice One Dose,

Next Choice, Levonorgestrel

Ulipristal acetate – containing pills

Ella

Progestin and Estrogen – containing pills

many brands of combined daily birth control pills

Mifeprestone – containing pills

(only available in China, Vietnam, Armenia and Russia)

Copper-T IUD

can be used for ongoing contraception for 10 years

Effectiveness of Combined Pills for Emergency Contraception

100 women have a single act of unprotected intercourse

Emergency contraception not used:

8 women would become pregnant

Emergency contraception used:

2 women would become pregnant (Preven)

Prevents 6 out of 8, or 75% of expected pregnancies

[graphical illustration of above statistics]

Effectiveness of Progestin Only Pills for Emergency Contraception

100 women have a single act of unprotected intercourse

Emergency contraception not used:

8 women would become pregnant

Emergency contraception used:

1 woman would become pregnant (Plan B)

Prevents 7 out of 8, or 85% of expected pregnancies

[graphical illustration of above statistics]

ECPs Are Most Effective When Taken Early

[graphed data showing that ECP prevents the most pregnancies when taken within 24 hours

compared to 25-48 hours, or 49-72 hours]

[picture of the journey of the egg from ovary to uterus with timing of milestones

12-24 hours egg is fertilized

3 days zygote arrives at end of fallopian tube

4 days zygote arrives at large space in uterus

4 ½ - 5 days embryo “hatches” out of “shell”

5 ½ - 6 days embryo implants]

Fertility Awareness Methods

(Natural Family Planning)

Mucus Method (Ovulation Method)

“read” vaginal secretions

“fertile period” = 9-15 days / menstrual cycle

Calendar Method (Rhythm Method)

predict cycle based on previous menstrual history

(requires accurate records for one year)

fertile period depends on variability of cycle

Basal Body Temperature (BBT) Method

measure temperature immediately upon waking

detect a drop just prior to ovulation

(and a rise just after ovulation)

[pictures illustrating appearance of mucus at various stages of the menstrual cycle]

A – immediately after period – very little cervical mucus – dry feeling around vagina

B – a few more days into the cycle – sticky or creamy mucus – slippery feel around vagina

C – as ovulation nears – mucus increases in quantity and becomes clear and stretchy

charting key

P = period

D = dry

S = sticky

F = fertile

[picture of sample charting data for mucus method]

rules for intercourse while monitoring cervical mucus to avoid pregnancy

menses – abstain

thick mucus or dry days – intercourse permitted on alternate days ??? or avoided ???

sticky mucus days – abstain

fertile mucus days – abstain

thick mucus or dry days – intercourse permitted beginning on the 4^th day after the last days of wet, stretchy mucus

A – fertile: cervix – high and central in vagina

os – wet and open

B – infertile: cervix – tilted back and lower in vagina

os – drier and closed

[pictures of fertile and infertile uterine/cervical/os findings]

calendar charting

calculation of the fertile period rests on three assumptions

ovulation occurs on day 14 (plus or minus 2 days) before the onset of the next menses

sperm remain viable for 2-3 days

ovum survives for 24 hours

to use the calendar method a woman must first maintain a menstrual calendar

recording the length of each of her menstrual cycles

over the most recent eight-month span

the first day of menstrual bleeding or even light spotting is day 1 of a cycle

[graphical illustration of 14 days between ovulation and next bleed, regardless of cycle length]

shortest first unsafe longest last unsafe

cycle day cycle day

21 days 3^rd day 21 days 10^th day

22 days 4^th day 22 days 11^th day

23 days 5^th day 23 days 12^th day

24 days 6^th day 24 days 13^th day

25 days 7^th day 25 days 14^th day

26 days 8^th day 26 days 15^th day

27 days 9^th day 27 days 16^th day

28 days 10^th day 28 days 17^th day

29 days 11^th day 29 days 18^th day

30 days 12^th day 30 days 19^th day

31 days 13^th day 31 days 20^th day

32 days 14^th day 32 days 21^st day

33 days 15^th day 33 days 22^nd day

34 days 16^th day 34 days 23^rd day

35 days 17^th day 35 days 24^th day

chart of basal body temperature during a model menstrual cycle

[picture of sample BBT (basal body temperature) chart]

use a digital thermometer

or a glass one specifically designed to take your BBT

[pictures of thermometers]

traveling, drinking a lot of alcohol, and late nights can raise your temperature

drawing a cover line helps identify the post-ovulatory temperature rise

[picture of sample BBT (basal body temperature) chart]

a woman may ovulate as early as day 7

assume fertility from the beginning of the cycle or no later than day 4

(if cycles > 25 days long)

until the temperature has remained elevated

(a rise of 0.4-0.8^oF compared to preceding 6 days)

for 3 consecutive days

if a sustained rise cannot be detected a woman may not have ovulated in that cycle

one study found that six out of 30 women had no identifiable BBT pattern in a cycle

when hormone tests clearly documented ovulation

[picture of symptothermal chart

recording the basal body temperature, mucus, and sexual activity of the user]

Standard Days Method

for women with menstrual cycles between 26 and 32 days long

failure rate = 12 (typical use)

cost = $12.95 retail

http://www.irh.org/pdf/CycleBeadsWashPostJuly04.pdf

[picture of Cycle Beads

Black Tube

This tube does not represent a day of the cycle.

It has an arrow that shows which direction to move the ring]

[picture of Cycle Beads

First Day of Period

Day 1:

The red bead represents the first day of a woman’s period.

She puts the ring on this bead on that day.

There is a VERY low risk of pregnancy on this day.]

[picture of Cycle Beads

Menstruation & After

Days 1 through 7:

Dark beads represent the days of a woman’s menstrual cycle

when there is a VERY low risk of pregnancy.]

[picture of Cycle Beads

Fertile Window

Days 8 through 19:

Light beads represent the days of a woman’s menstrual cycle

when she is likely to get pregnant.]

[picture of Cycle Beads

Low Fertility

Days 20 through 32:

Dark beads represent the days of a woman’s menstrual cycle

when there is a VERY low risk of getting pregnant.]

[picture of Cycle Beads

The Darker Bead

The darker bead helps women to know if they have cycles that are shorter than 26 days.

If a woman has her period before she puts the ring on this bead,

she has had a cycle that is shorter than 26 days.

If this happens more than once in a year, this method is probably not appropriate for her.]

[picture of Cycle Beads

End of Cycle

Days 27- 32:

The day a woman starts her next period, no matter what bead the ring is on,

she should move the ring to the red bead.

Then the process starts over.]

[picture of Cycle Beads

Last Bead

Day 32:

If a woman has not had her period by the day after she puts the ring on this bead,

she is having a cycle longer than 32 days.

If this happens more than once in a year, this method is probably not appropriate for her]

http://www.cyclebeads.com/smartphones

[picture of CycleBeads app on smartphone]

ovulation predictor kits

utilize a urine test

detect LH surge that triggers ovulation

typical kit contains 5 sticks

to be used on consecutive days around the time of ovulation

[picture of woman checking an ovulation stick]

[picture of biological events of the menstrual cycle

including the large LH surge preceding ovulation]

difficulties with fertility awareness methods

require a considerable length of time to master before they can be used

difficult for women with irregular cycles

some women are unable to see clear patterns in mucus changes or BBT changes

difficulties continued

vaginal infections, semen, contraceptive foams, jellies, and creams,

may make it hard to observe mucus changes

sperm can remain alive up to 72 hours, so pre-ovulatory temperature drop

does not occur far enough ahead of time to safely avoid coitus

ovulation and menstruation may vary due to factors

such as illness, fatigue, or emotional extremes

method failure rate

best typical

Standard days 5 12 0*

Calendar/BBT/mucus 9 20 0*

*1 year with 100 occurrences of intercourse

female sterilization - tubal sterilization

blocks movement of egg & sperm

complications:

gas pain, incision pain, accidental burnt tissue

post-surgical bleeding, anesthesia risks

surgical reversal sometimes successful

up to 75% pregnancy rate

[picture of tubal sterilization procedure]

tubal sterilization techniques

[picture of tubal sterilization procedure modifications]

Essure system – 2 soft metallic coils

FDA approved as of November 2002

fibers laced through coils stimulate local fibrotic response occlude the tubes over 3 months

patients may go home about 45 minutes after the procedure

[picture of Essure placement]

bilateral placement achieved in 86% on 1^st attempt

and another 4% on 2^nd attempt

(in one study of 518 women)

no pregnancies reported in 439 women

who relied on it for 12 mo

(and 16 women for 24 mo)

male sterilization by vasectomy

safer & cheaper than tubal ligation

vasovasostomy: reversal of vasectomy (pregnancy rate 50%)

[pictures of steps in the vasectomy procedure:

(1) The vas deferens is located.

(2) A small incision in the scrotum exposes the vas.

(3) A small section of the vas is removed, and the ends are cut and/or cauterized.

(4) The incision is closed.

(5) Steps 1-4 are repeated on the other side.]

method failure rate

best typical

tubal sterilization 0.5 0.5 $1,200-$2,500*

vasectomy 0.1 0.2 $250-$1,000*

*1 year with 100 occurrences of intercourse

Less-Than-Effective Methods

nursing

withdrawal

douching

nursing

breast feeding delays return of fertility after childbirth

nearly 80% of breast-feeding women ovulate before their first menstrual period

withdrawal

it may be difficult to judge when to withdraw

preejaculatory Cowper’s gland secretions may contain sperm

sperm deposited on labia can swim into vagina

douching

after ejaculation some sperm reach the inside of the uterus in a matter of 1-2 minutes

water from douching may actually propel sperm toward cervical opening

method failure rate

best typical

withdrawal 4 24 0*

*1 year with 100 occurrences of intercourse

percent of women using various contraceptive methods

1995 CDC Website; 1988 & 1982 Larry J Copeland: Textbook of Gynecology

1995 1988 1982

female sterilization 17.8 16.6 12.9

male sterilization 7.0 7.0 6.1

other sterile (noncontraceptive or nonsurgical) 4.3 5.3 8.1

pregnant / postpartum 4.6 4.8 5.0

seeking pregnancy 4.0 3.8 4.2

nonuser (never had intercourse 10.9-13.6%) 35.8 25 26.9

pill 17.3 18.5 15.6

condom 13.1 8.8 6.7

IUD 0.5 1.2 4.0

diaphragm 1.2 3.5 4.5

periodic abstinence 1.5 1.4 2.2

withdrawal 2.0 1.3 1.1

implant 0.9

injectable 1.9

Contraceptive Prevalence in 4 Countries

[graph showing significant differences in contraceptive use in 4 countries]

http://www.malecontraceptives.org

malecontraceptives.org