Contraception

The student will have a working knowledge of current contraceptive methods, including indications and contraindications for each type.

General Statements

• The primary mechanism of action is the prevention of ovulation.
• Modern oral contraceptives (OCs) contain both estrogen and progestogen in each tablet.

• Reasons to use OCs:

• Effective
• Easy to use
• Good compliance
• Safety

• Either monophasic or multiphasic pills may be used.
• Lower dose OCs are safer and are recommended (30 or 35 mg estrogen).

• Newer progestins-- desogestrel, gestodene, norgestimate-- are more selective to progesterone receptors and less androgenic. They also offer theoretical benefits in patients with features of androgenic excess (acne or hirsutism). Effects on the LDL/HDL ratio are also theoretically beneficial, but the effect is small and not proven to be clinically important.

• Thrombophlebitis or thromboembolic disorders.
• Past history of deep thrombophlebitis, thromboembolic disorders or MI.
• Cerebral vascular or coronary artery disease.
• Known or suspected cancer of the breast.
• Known or suspected estrogen-dependent neoplasm (endometrium)
• Undiagnosed, abnormal genital bleeding.
• Known or suspected pregnancy.
• Markedly impaired liver function; active hepatitis.
• Congenital hyperlipidemia.
• Smokers over age 35.

• Migraine headaches - may have an increased risk of stroke.
• Hypertension - if healthy, under age 30, and blood pressure controlled on medication, can elect to use OC.
• Uterine fibroids - use low dose pill if desired.
• Elective surgery - discontinue OC one month prior to surgery to avoid post-operative thrombosis.
• Seizure disorder - not proven to exacerbate epilepsy.
• Hemoglobin SS or SC diseases (not sickle trait).
• Gallbladder disease.
• Diabetes mellitus; gestational diabetes - requires monitoring.
• Obstructive jaundice in pregnancy.

• Determine exactly what the patient wants.

• Some want counseling about all forms of contraception and time to make a decision.
• Some simply want a prescription.

• Find out exactly what the patient is worried about.

• Most patients are aware of some relationship between OCs and Òblood clotsÓ or cancer.
• Many have some special fear - real or imaginary.

• Rule out contraindications by history (see checklist of absolute and relative contraindications, items II and III above).
• Identify other risks by history, e.g. smoking.

• Examine the patient:

• Pelvic exam; pap smear, if timely.
• Include BP; breast exam.

• Give the patient a personal risk estimate:

• Risk is low for a healthy, 17 year old girl.
• Risk is high for a 37 year old woman who smokes.

• Prescription

• Thoroughly learn about several low-dose OCs, and become comfortable with their use.
• Look up unfamiliar OCs, if necessary.
• Find out if the patient prefers a 21-day or 28-day package.
• Give specific oral instructions regarding OC use.

• May begin on 5th day of next period (21-day packet).
• May begin on Sunday nearest to next period (28-day packet) (never menstruating on a weekend).
• May start anytime if a wait is not possible.
• Must use other contraception (e.g. foam + condom) during first cycle (counsel re STDs, including HIV).
• Instruct patient about missed pills and importance of not extending the 7-day interval between pill cycles.
• The actual prescription may be written simply. Detailed instructions are given orally and on package insert.

• Changes in menstruation:

• Amount and duration of menstruation may change.

• Low-dose OCs often cause lighter periods, mid-cycle spotting, or even amenorrhea, which are inconvenient but not indicative of pathology.

• Amenorrhea.

• Breakthrough bleeding:

• Always determine how the patient is taking the OC. Skipping one or two doses may cause spotting. failure to take the OC in proper sequence may cause abnormal bleeding.

• Breakthrough bleeding during the first few months is best treated by encouraging the patient to tolerate this, since it usually disappears within 3 cycles. If intolerable, give 7 days of additional estrogen (Premarin 2.5 mg or ethinyl estradiol 20 mg). Changing to another low dose formulation may be effective.

• Breakthrough bleeding may occur after many months on low estrogen OC, due to atrophic endometrium. This is best treated by adding an estrogen to the OC for 7 days, as above.

• The OC carries greater risks as the patient ages, but the risk is healthy women is less than that associated with pregnancy (especially after age 40). Low dose OCs may be used with healthy non-smokers until menopause. HTN, hypercholesterolemia, and DM become absolute contraindications in the 36-50 age group.

• Giving OC to breast-feeding mothers is not generally recommended. An OC may stop lactation; ? effect on baby.

• Rifampin, coumadin, phenytoin, primidone, carbamazepine, and phenobarbital may decrease OC effectiveness by altering liver metabolism, so donÕt use OC. Patients on ampicillin and tetracycline also should use additional contraception.

• When starting a patient on an OC for the first time, it is advisable to have her return in 2-3 months to answer questions and ask about the occurrence of side effects. Thereafter, yearly visits are adequate.

Mechanism of Action: thickened cervical mucus, atrophic endometrium, and suppression of ovulation (not complete); good contraception, but poor cycle control.

Norplant

• Side effects:

• menstrual changes - 80%
• weight gain - 32%
• headache - 24%
• mood changes - 24%
• acne - 15%
• breast tenderness and galactorrhea.

• Complications of insertion: Infection, expulsion, local reactions, peripheral neuropathy.

• Norplant removal: Difficult removals in 13% during clinical trials. Techniques: standard, Emory, "pop-out," "U," "modified U."

• Patient selection: Consider probability of noncompliance and tolerance of side effects; thorough patient education.

• No weight limit with current Norplant, but lower effectiveness in women over 70 kg during the fourth and fifth years (still better than oral methods).

• History: Used in many countries for more than 20 years.
• Dosage: 150 mg IM every 3 months; first dose during first 5 days of a menstrual cycle.
• Ovulation is unlikely and amenorrhea is more likely than with Norplant.
• Other side effects similar to Norplant.
• Conception delay of about 9 months after last injection.
• Consider in patients with seizure disorder, since improvement in seizure control may occur.
• Other benefits: Decreased risk of endometrial cancer, fewer ectopic pregnancies, less PID, less endometriosis.

The most popular method of reversible contraception worldwide, it is now used by only 1% of women in the U.S. Previously popular in this country in the 60s and 70s, problems with the Dalkon Shield caused public concern about all IUDs.

Copper-containing IUDs were the safest and most effective. However, the Cu-7 was taken off the market in 1986 (litigation had made it unprofit-able), and none were available in the U.S. until the Paragard T380A was approved in 1990. It is approved for up to 10 years of use.

• The mechanism of action is thought to be through spermicidal effects of the copper.

• Progestin-releasing IUDs have additional effects on the cervical mucus to inhibit sperm penetration. They also diminish cramping and blood loss.

• Ectopic pregnancies are reduced in frequency by the medicated IUDs (90% less chance of ectopic than with no contraceptive).

• Side effects: Increased menstrual flow and increased menstrual cramps.

• Health risks: Infections are most likely a result of contamination during insertion. Intrauterine pregnancy with an IUD in place can lead to a septic abortion (20x increased risk).

• Patient selection: Consider menstrual history and risk for STDs (number of partners, partner's practices, age at onset of intercourse, prior STDs). No uterine abnormality on exam, and should sound between 6 and 10 cm.

• Insertion, removal, localization if displaced.

• Use as one-time, "emergency" method (rape, condom breakage, etc.).

• High doses of estrogen prevent implantation (ethinyl estradiol 2.5 mg bid x 5 d, Ovral 4 tabs over 12 hours, or LoOvral 8 tabs over 12 hours).

• Begin treatment no later than 72 hours after exposure.

• Screen for preexisting pregnancy.

• RU486 (progesterone antagonist) 600 mg is more effective and causes less nausea and vomiting.

Speroff L, Glass RH, Kase NG, Clinical Gynecologic Endocrinology and Infertility, 5th ed. Baltimore: Williams and Wilkins, 1994: 687-806.