Med Clin N Am 92 (2008) 10371058

Contraception: What Every Internist Should Know

Eve Espey, MD, MPHa,*, Tony Ogburn, MDb, Dana Fotieo, MDc
Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 08 4700, 1 University of New Mexico, Albuquerque, NM 87131, USA b Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA c Department of Internal Medicine, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131, USA
a

The longstanding epidemic of unintended pregnancy in the United States continues unabated. Although the rate of unplanned pregnancy has declined somewhat over the last two decades, it continues to hover around 50% [1]. No other developed country has a rate this high. The human costs of unintended pregnancydabortion and parenting under dicult circumstancesd are high. For this reason, all physicians who treat female patients should be knowledgeable about the basics of contraceptiondboth its practical uses and its public health impact. This knowledge will make physicians, including internists, better able to counsel and provide contraceptives for individual patients and to advocate for availability and access. This article discusses the problem and determinants of unintended pregnancy. Contraceptive methods, particularly the long-acting reversible contraceptives, are reviewed and their potential impact on unintended pregnancy is examined.

Barriers to reducing unintended pregnancy Of the approximately 6 million pregnancies each year in the United States, about half are unintended [2]. Of these, approximately one million, or 42%, are aborted. Not only is the United States unintended pregnancy rate the highest of developed countries, but the abortion rate and teen
* Corresponding author. E-mail address: eespey@salud.unm.edu (E. Espey). 0025-7125/08/$ - see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2008.05.001 medical.theclinics.com

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pregnancy rate are similarly high [3]. European countries have far lower unintended pregnancy, teen pregnancy, and abortion rates. Why is one of the richest nations in the world plagued by such poor reproductive health statistics? The answer lies in the unique social, political, and medical landscape in the United States. Socially, we have made the decision to tie health care to an employer-based insurance system that does not cover all Americans, often does not cover all contraceptives, and does not adequately cover costs even when contraceptives are included. Additionally, we remain an odd blend of commercialism and prudishness [4]. Capitalism drives unbridled sexuality in the media but Puritan roots drive a strong reluctance to discuss sexuality as a normal component of human behavior, leading to the illogical but widely adopted implementation of abstinence-only sex education. Bipartisan politics hold womens reproductive health hostage: increasingly, contraception and abortion come under the purview of politics, not of the health care system. Far reaching reproductive health decisions are made by courts instead of by patients and their physicians. Medically, the birth control pill continues to dominate the reversible contraceptive market in the United States, despite our knowledge that other methods work much better in typical use. Intrauterine contraception and implantsdsimilar in the lack of patient compliance required for usedare the gold standard of reversible contraception, yet are used by a fraction of women because of attitude, training, and cost barriers [5]. Abstinence-only sexuality education Over the last decade, the federal government has allocated over a billion dollars to abstinence-only sexuality education for teenagers. Abstinenceonly education specically prohibits education about contraceptives and has been adopted throughout the country. From 1995 to 2002 formal instruction about birth control methods declined from 81% to 66% for adolescent males and from 87% to 70% for females [6]. No federal money has been allocated to comprehensive sexuality education, in which abstinence is stressed but contraceptives are discussed. Not only do most Americans believe that contraception and sexually transmitted infection (STI) prevention should be included in sexuality education [7], but professional organizations, including the American College of Obstetrician Gynecologists, also support a more comprehensive approach [8]. European countries, such as Sweden and the Netherlands, both with much lower rates of unintended pregnancy and abortion, are known for early and accurate sexuality education coupled with easy access to contraceptives [9]. Lack of access to contraceptives: no insurance, underinsurance and insurance regulations Lack of adequate insurance is a barrier to contraceptive use. It is estimated that one in ve reproductive-aged women was uninsured in

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2003 [10]. About 17 million women depend on publicly funded family planning services. Despite the rapidly growing population segment that requires assistance to access family planning, funding for family planning has been reduced or remained at over the last decade. Federal Healthy People 2010 goals include Increasing the proportion of health insurance policies that cover contraceptive supplies and services [11], yet no federal law requires contraceptive coverage and only 26 states have enacted contraceptive equity laws [12]. Such laws improve access to contraceptives, with the full range of contraceptives oered by 90% of insurance companies in states with equity laws compared with only 56% in states without such a law [13]. Additional barriers to contraceptive use even in women with insurance include:  Co-pays and deductibles. These are often high enough to discourage consistent contraceptive use: women pay substantial out-of-pocket costs for contraceptives, higher than those for other medications [14]. In European countries, all women have insurance coverage and contraceptives are universally covered.  One month at a time. The majority of insurers dispense only 1 month of contraceptives at a time with a co-pay required each month. Women may only access the next month of contraceptives within a narrow window of time with the net eect of obstructing consistent contraceptive use. This may be cost-saving in the short run but impedes consistent contraceptive use, resulting in increased overall costs. Societal supports for unintended pregnancy and early motherhood In contrast to school based abstinence-only messages, the content of media is sexually explicit. Over 70% of shows geared to teens include sexual content, though little of that content promotes responsible sexuality [15]. Ironically, networks have highly restrictive policies about advertising for birth control but advertisements for male erectile dysfunction are widespread. The combination of sexually charged media and reduced access to contraceptive information and supplies may be a major determinant of unintended pregnancy. Teenagers in the United States are more likely than teens in other countries to become pregnant and to continue their pregnancies. United States teens still have more abortions than teens in other developed countries because of the high rate of unplanned pregnancy in United States adolescents [9]. Surveys reveal that United States teens are more likely to desire motherhood than teens in other countries [16]. Poverty and social disadvantage increase the risk of early childbearing and unplanned pregnancy, but teens across the socioeconomic spectrum in the United States are more likely to experience unplanned pregnancy than their counterparts in other countries. Investigators have speculated that one factor explaining decreased teen childbearing in other countries is the strong social support for the concept of reserving parenting for

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adulthood. Similarly, the acceptance of sexual activity in young people and the pragmatic approach of making sexuality education and contraceptives readily available are features of European countries that have low unplanned pregnancy and abortion rates [16]. In the United States, well-intentioned social supports are designed to assist teen mothers. Special schools allow young mothers to return to school and nancial aid assists with health care and food purchases. These supports may paradoxically serve an enabling role and send a message that teen pregnancy is acceptable. Choice of method A major reason for high-unintended pregnancy may be the top methods chosen by American women. In the 2002 National Survey of Family Growth, a periodic survey conducted by National Center for Health Statistics, the most common three methods in order were oral contraceptives (used by 31% of reproductive-aged women using contraception), followed by female sterilization (27%) and condoms (18%) [5]. Other methods are used much less commonly. Although sterilization is an extremely reliable form of contraception, the two most commonly used reversible methods, condoms and oral contraceptive pills, are prone to inconsistent use and human error. Both methods are plagued by typical use pregnancy rates that deviate greatly from perfect use rates (Table 1). Additionally, to determine the true eectiveness of a contraceptive method, the likelihood of continuing that method must factor into the equation. Although oral contraceptive continuation is relatively high, use of condoms has a very low continuation. The World Health Organization has dened the hierarchy of contraceptive methods, from most eective (top tier) to least eective. The top tier contraceptivesdintrauterine devices (IUDs), implants, and sterilizationd all have in common that no ongoing compliance is required for long-term use (Fig. 1). Of the three, only sterilization is widely used in the United States. Contraceptive implants have just reappeared on the American market after a hiatus of 6 years. A six-rod contraceptive implant, removed from the market in 2000, was used by fewer than 5% of contraceptive users. The extent of use of a new one-rod implant available in the United States since 2006, is unknown at this time. The IUD, the most common method of reversible contraception worldwide, is used by only 1.3% of American women contraceptive users. Unfortunately, the IUD is still plagued by an unearned negative reputation, perpetuated by both the public and by physicians. Physicians can play a major role in improving womens ability to contracept by becoming knowledgeable about current safety and acceptability data for long-term forgettable contraceptives and advocating for these safe, long-term methods. Increased use of IUDs, implants, and sterilization could have a signicant impact in reducing the rate of unintended pregnancy in the United States.

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Table 1 Contraceptive failure rates- perfect versus typical use First-year contraceptive failure rates Method Pill (combined) Tubal sterilization Male condom Vasectomy 3-month injectable Withdrawal IUD Copper-T IUD Periodic abstinence Calendar Ovulation method Sympto-thermal Post-ovulation 1-month injectable Implant Patch Diaphragm Sponge Women who have had a child Women who have never had a child Cervical cap Women who have had a child Women who have never had a child Female condom Spermicides No method Perfect usea 0.3 0.5 2.0 0.1 0.3 4.0 0.6 0.1 9.0 3.0 2.0 1.0 0.05 0.05 0.3 6.0 20.0 9.0 26.0 9.0 5.0 18.0 85.0 Typical use 8.0 0.5 15.0 0.15 3.0 27.0 0.8 0.1 25.0 25.0 25.0 25.0 3.0 0.05 8.0 16.0 32.0 16.0 32.0 16.0 21.0 29.0 85.0

a Most perfect-use rates have been clinically evaluated, but some are based on clinical expertise or best guesses (such as some forms of periodic abstinence, withdrawal and no method use). Data from Guttmacher Institute. Facts on contraceptive use. Available at: http://www. guttmacher.org/pubs/fb_contr_use.html. Accessed June 30, 2008.

Contraceptive methods Intrauterine contraception IUDs are small, T-shaped, plastic devices inserted in the uterus (Figs. 2 and 3). The hormonal IUD, the levonorgestrel (LNG) intrauterine system, and the copper IUD (Copper T380A) are the two IUDs available in the United States. Both are highly eective, with low failure rates and work primarily by preventing fertilization because of an intrauterine sterile inammation that is spermicidal. Costs of IUDs are front-loaded: they are relatively expensive and insertion fees are high. However, over time IUDs are the most cost-eective of available birth control methods.

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Fig. 1. Comparative eectiveness of contraceptive methods. (Courtesy of Family Health International, Durham, NC. http://www.fhi.org/nr/shared/enFHI/Resources/EectivenessChart.pdf; with permission.)

Fig. 2. Copper T380A intrauterine device. (Courtesy of Barr Pharmaceuticals, Inc., Pomona, NY; with permission. Copyright 2008 Duramed Pharmaceuticals, Inc. All rights reserved.)

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Fig. 3. LNG-IUS intrauterine device. (From Gupta S. Non-oral hormonal contraception. Curr Obstet Gynaecol 2006;16:34; with permission.)

Levonorgestrel intrauterine system and copper (T380A) IUD The LNG intrauterine system (IUS) is eective for 5 years and has a failure rate of less than 1%. It releases a small amount of progestin into the uterus that thins the endometrium. During the rst 1 to 3 months of use, the LNG-IUS may cause irregular spotting and bleeding, but thereafter typically causes a substantial reduction in menstrual blood loss. Approximately 20% of users become amenorrheic. The copper IUD is eective for 10 years and also has a failure rate of about 1%. The copper IUD may initially cause heavier menses and dysmenorrhea, although these usually decrease with time. Most women are good candidates for IUDs, even young nulliparous women. Despite its reputation, the IUD does not cause pelvic inammatory diseasedexcept for a brief period of slightly increased risk at the time of insertiondor infertility [17,18]. It is not an abortifacient, as it prevents fertilization or implantation but does not disrupt an established pregnancy [19]. The IUD is an acceptable option for women with a history of ectopic pregnancy [20]. Intrauterine contraception may be particularly suitable for women who have medical problems, such as history of thromboembolism, hypercoagulable disorders, or migraines with aura, in whom estrogen is contraindicated [19]. Advantages and disadvantages Intrauterine contraception is highly eective and requires no action after placement of the device. User satisfaction with the IUD is excellent and return to fertility occurs as soon as the IUD is removed. Disadvantages include the small risk of uterine perforation (about 1 in 1,000 insertions), expulsion (about 3%), and infection (the risk of pelvic infection is slightly increased for the rst 20 days after insertion). The copper IUD has no hormonal content, so it is a good choice for women who wish to avoid

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hormones as well as women who are breastfeeding. The LNG-IUS may cause irregular unpredictable bleeding, typically limited to the rst 1 to 3 months of use. IUDs do not protect against STIs. In general, for most women advantages of the IUD far outweigh the disadvantages. Etonogestrel implant A new contraceptive implant on the market is a single rod inserted under the skin of the upper arm (Fig. 4). It releases a synthetic progestin, etonogestrel, and protects against pregnancy by preventing ovulation. The method is highly eective for up to 3 years, with a failure rate of less than 1% [21]. The implant may be placed by trained physicians and advanced practice clinicians. The simple procedure only takes approximately 5 to 10 minutes. The implant is placed in the medial aspect of the upper arm, using a small amount of local anesthetic. It is placed directly into the skin through a large bore needle inserter. Signicant pain or other complications are rare with the procedure. Removal of the implant is also typically straightforward, with rapid return to fertility. As with the IUD, up-front costs are relatively high, but this device is highly cost eective over time. Advantages and disadvantages The major advantages of the implant are its outstanding eectiveness and its convenience: no action is required on the patients part after placement of the device. The major disadvantage of the implant is irregular bleeding, which may last for the entire 3 years of the implant [22]. The bleeding is typically light or spotting, but is unpredictable. Despite the irregular bleeding, continuation is excellent. Over 90% of women continue the method at 1 year and 72% at 3 years [23].

Fig. 4. Etonogestrel-releasing contraceptive implant disposable applicator. (From Funk S, Miller MM, Mishell DR, et al. Safety and ecacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contraception 2005;71:320; with permission.)

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Sterilization Female and male sterilization together constitute the leading method of contraception in the United States. Tubal sterilization may be performed laparoscopically, through a mini-laparotomy, or hysteroscopically. Tubal sterilization is a permanent and highly eective method, with a lifetime failure rate of 1% or less [24]. Laparoscopic or postpartum tubal sterilization In interval laparoscopic procedures, the fallopian tubes are closed by tying, banding, clipping, cutting, or sealing them with electric current. These procedures are routinely done under general anesthesia in an operating room, usually as an outpatient surgery. The abdomen is typically insuated with CO2 gas and instruments are placed through one or two small incisions in the abdomen. Postpartum tubal sterilization is accomplished through a mini-laparotomy, usually within 1 to 2 days of a vaginal delivery. A small incision is made just below the umbilicus and the tubes are grasped, tied, and cut. The same procedure may be used for women undergoing sterilization at cesarean section. Hysteroscopic sterilization Transcervical sterilization is a recent option for permanent sterilization (Figs. 5 and 6). There is only one currently available micro-insert method in the United States, though an additional method is currently undergoing clinical trials and is anticipated to be available in the near future. Both are performed via hysteroscopy. The currently available method is highly effective, with a failure rate of less than 1%, does not involve any incisions, can be done in a doctors oce, and does not require anesthesia [25]. The procedure is performed via hysteroscopy, where a small scope is placed through the cervix into the uterus. Under direct visualization, a small spring-like coil is inserted into each fallopian tube. The device causes

Fig. 5. Transcervical sterilization. (Courtesy of Conceptus, Inc., Mountain View, CA; with permission.)

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Fig. 6. Transcervical sterilization microinsert component. (Courtesy of Conceptus, Inc., Mountain View, CA; with permission.)

inammation and scarring, with resulting brous ingrowth, occluding the fallopian tube. It takes up to 3 months for tubal occlusion and a hysterosalpingogram (HSG) must be performed to verify that the tubes are blocked. The HSG is a uoroscopic examination in which dye is injected into the uterus, verifying lack of tubal patency. Advantages and disadvantages The major advantages of tubal sterilization are its permanence and that no action is required on the patients part after the procedure is performed. Advantages of the transcervical approach are the ability to perform the procedure in the oce without anesthesia and minimal risk of complications. The major disadvantages to laparoscopic and postpartum tubal sterilization are the requirement for regional or general anesthesia, initial costs, and rare but potentially life threatening complications (vessel laceration, bowel perforation). The major disadvantages of hysteroscopic sterilization are the 3-month delay before it works and the requirement for an HSG. The major disadvantage of all forms of sterilizations is the diculty or impossibility of reversal if a woman changes her mind. Sterilization for men A vasectomy works by blocking the tubes that carry sperm from the testes to the penis, preventing the release of sperm. The vasa are tied, cut, clipped, or sealed through one or two small cuts in the skin of the scrotum. Some doctors use a no-scalpel technique. There is minimal data to determine which method is best, though fascial interposition may improve ecacy while the no-scalpel technique is associated with fewer complications [26,27]. These procedures may be done in a doctors oce, clinic, or hospital. Typically 3 months are required for the sperm count to decline to the point that the couple may rely on the method. A nal sperm count is required to ensure sterility. Reported failure rates are typically 1% or

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less, similar to that of female sterilization [28]. Advantages of male sterilization include its lower expense and fewer signicant complications compared with female sterilization. Obviously, if a woman has a new partner she will not be protected. Depo-medroxyprogesterone acetate Depo-medroxyprogesterone acetate (DMPA) is an injection that provides protection from pregnancy for 3 months. It is a highly eective form of contraception with a very low failure rate of approximately 0.1% when used correctly. Typical use failure rates are approximately 3% [29]. The method consists of a large dose of medroxyprogesterone that prevents ovulation and thickens cervical mucus [30]. DMPA is an alternative for women who have diculty using daily or weekly birth control methods, like the pill or patch. Injections are also an alternative for women with contraindications to estrogen containing hormonal methods, such as those at high risk for thromboembolism and smokers over age 35. Advantages and disadvantages Advantages of DMPA include its four-times-a-year dosing and the eventual side eect of amenorrhea in most women. Disadvantages include irregular bleeding and possible weight gain. Although most women become amenorrheic when on DMPA long-term, women can experience up to a year of irregular bleeding before becoming amenorrheic. Current use of DMPA is associated with a decrease in bone mineral density, particularly with long-term use (ie, over 2 years) [31]. Women on DMPA should engage in weight bearing exercise and have adequate calcium and Vitamin D intake. Bone loss reverses after injections are stopped, though it is unclear whether the reversal is complete [32]. Though there is at least a transient loss of bone density with DMPA use, data are reassuring that women who used DMPA in the past do not have more fractures than women who did not use DMPA. It is not recommended to limit the duration of DMPA use in a young, healthy woman if it is deemed to be the best form of contraception for her. Bone density measurements are not recommended. Another disadvantage of DMPA is the potential delay in return to fertility after stopping use. It may take 9 to 18 months to ovulate again after cessation of DMPA, which should be considered for patients considering a pregnancy in the near future [33]. Combined hormonal contraceptives: birth control pills, patch, and vaginal ring These prescription methods use a combination of two hormonesestrogen and progesterone. All combination methods work primarily by preventing ovulation [34]. Combination methods are highly eective and have several noncontraceptive benets, the most recognized of which is cycle controldmaking menses regular, light and less painfuldand are often used for

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this purpose even in women who do not require contraception. Additional noncontraceptive benets are reduction in acne and reduction in risk of uterine and ovarian cancer that may be as great as 40% to 50%, depending on length of use [35,36]. Signicant risks of combination methods are few. Combination methods increase the risk of deep venous thrombosis, but much less than the risk conveyed by pregnancy. Certain medical conditions constitute a contraindication for combination methods, including a history of thromboembolic disease, uncontrolled hypertension, migraine headache with aura, cardiovascular disease, and active liver disease [37]. An IUD or a progestin-only method, such as an etonogestrel implant, may be a better choice for such patients. Birth control pills Combination pills contain the hormones estrogen and progestin. They are highly eective when taken every day, with perfect use failure rates of less than 1%. However, the typical failure rate of combination birth control pills is 3% to 8% and much higher in some populations [38]. The range is wide because so much depends on whether women can be adherent to a daily pill regimen. Side eects of the pill, including breast tenderness, nausea, headaches, and bloating, are usually limited to the rst 1 to 2 months of use, but may discourage continuation. A backup method of birth control, such as condoms, should be used for the rst week after pills are started. Few clinical dierences have been noted among the myriad dierent pill formulations (monophasic, biphasic, triphasic, dierent generation progestins, and other formulations) so it is reasonable to prescribe a generic monophasic pill containing 30 to 35 micrograms of estrogen for most patients [39]. A recent development in combination pills are the extended dosing regimens. Three dedicated products package the pills in extended dose regimensd two in packs of 84 active pills followed by 7 placebo or low dose days, and one in packs of 28 active pills. These regimens may have the advantage of reducing scheduled bleeding. In the case of the 9-day packs, they have the additional advantage of ensuring that women have more pills on hand than the traditional one-pill pack at a time. Though studies have conrmed the safety and ecacy of these regimens, further studies are needed to determine the best formulations [40]. Progestin-only birth control pills contain only the hormone progestin and are often called the progestin-only pill or the minipill. They are not as widely used as combination pills because of their inferior ecacy and increased side eect prole. They are a better choice for women with problems, such as high blood pressure or smoking over age 35, which may be negatively impacted by estrogen containing pills. The progestin-only pill is often recommended for breastfeeding women.

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Advantages and disadvantages Birth control pills are very eective when taken daily. They make periods lighter, regular, and less painful, protect against endometrial and ovarian cancer, and can improve acne. Side eects are typically few and improve over time. Disadvantages include the need to take a pill daily and to get a prescription relled monthly. In addition, pills are contraindicated in women with certain medical conditions. Skin patch The contraceptive skin patch is a small (1.75 inch) adhesive patch that is worn on the skin (Fig. 7). The patch contains estrogen and progestin that are absorbed through the skin. The patch is worn for a week at a time for a total of 3 weeks in a row. During the fourth week, a patch is not worn, and a menstrual period occurs. After week 4, a new patch is applied and the cycle is repeated. Some patients have success using the patch in a continuous fashion: that is, using a new patch each week without having a patch free interval. Many patients will become amenorrheic with this approach but may experience irregular bleeding. A backup method of birth control, such as a condom, should be used for the rst week of the rst patch. The patch can be placed on the buttocks, chest (excluding the breasts), upper back, arm, or abdomen. It should be applied to a new place each week to avoid irritation. The failure rate of the patch is similar to that of the combination pill [41]. Concern has been raised that the ecacy of the patch may be decreased in obese patients; however, it is still highly eective

Fig. 7. Contraceptive patch. (From Swica Y. The Transdermal Patch and the Vaginal Ring: Two Novel Methods of Combined Hormonal Contraception. Obstet Gynecol Clin North Am 2007;34(1):3142; with permission.)

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if used correctly and is a reasonable choice if it is the best method for an individual patient, regardless of her weight [42]. Another concern with the patch is a possible increased risk of thromboembolic disease compared with pills. The risk is primarily theoretic because of higher total estrogen dosages, but is still much less than pregnancy [43]. Advantages and disadvantages Evidence suggests that it may be easier to remember the patch, but no major dierences in eectiveness between pill and patch have been shown. Side eects and noncontraceptive benets are similar to those of the pill. It may be a good option for patients who are not able to take oral medications. Vaginal ring Another combination estrogen and progestin hormone method is the vaginal ring (Fig. 8). It is made of exible plastic and is placed by the woman in the vagina for three weeks in a row. It also works primarily by preventing ovulation. After removal of the ring, menses period usually will start within 2 to 3 days. A new ring is inserted a week after the last one was removed. The ring may also be used in a continuous fashion with a new ring inserted once a month, with no ring free interval. Many women will become amenorrheic using this approach, though some will experience irregular bleeding. When a woman begins using the vaginal ring, she should use a backup

Fig. 8. Vaginal ring. (From Barnhart et al. In vivo assessment of NuvaRing placement. Contraception 2005;72:197; with permission.)

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method of birth control, such as condoms, for the rst 7 days of use. Rarely, the vaginal ring slips out of the vagina. If the ring is out of the vagina for more than 3 hours, a backup method of birth control should be used for 7 days. If the vaginal ring slips out often, is uncomfortable for the woman or her partner, or causes a discharge, a dierent method of birth control may be needed. The failure rate is similar to that of the combination pill. Advantages and disadvantages The ring, like the patch, has similar benets and risks as the birth control pill. The ring may be easier to remember than the pill because it only needs to be replaced once a month. A disadvantage is that some patients or their partners may feel the ring during intercourse, though this is typically not a reason for discontinuation. Barrier methods Condom The male condom is a thin sheath of latex (rubber), polyurethane (plastic), or animal membrane that is worn over the erect penis. Latex condoms not only protect against pregnancy, but are the only method to reliably protect against STIs, including HIV [44]. Condoms work better to prevent pregnancy when used with a spermicide. To be eective, a condom must be used with every act of intercourse. The failure rate with typical use is approximately 20%. Spermicides, used in conjunction with condoms, are put in suppositories, foam, cream, jelly, or lm (thin sheets) and kill or inactivate sperm. Advantages and disadvantages The major advantage of condoms is the strong protection they aord against STIs. Additionally, they are accessible and inexpensive. Disadvantages are that they are less eective than other methods, must be used with every act of intercourse, interrupt sex, and are perceived as messy, especially when used with spermicides. Sponge The sponge is a doughnut-shaped device made of foam instilled with spermicide. The sponge is wetted with water before intercourse and is inserted into the vagina, where it covers the cervix and blocks sperm from entering the uterus. The sponge may be put in the vagina up to 24 hours before sex and should be kept in place for at least 6 hours after sex. It should not be left in for more than 24 hours after sex. The sponge is relatively inexpensive and is available over the counter. The typical failure rate is high, at approximately 24% [45].

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Advantages and disadvantages Advantages include accessibility and relatively low expense. Disadvantages are its lower eectiveness than other methods and the need to use a sponge with every act of intercourse. Diaphragm The diaphragm is a small, latex dome-shaped device that ts inside the womans vagina and covers the cervix. It is relatively inexpensive and typically lasts for about two years. It works better when used with spermicide. The diaphragm can be inserted up to 6 hours before sex. After sex, the diaphragm must be left in place for 6 hours, but not more than 24 hours. A diaphragm requires a prescription and should be tted by a provider. The failure rate for the diaphragm with spermicide is about 13%. Advantages and disadvantages Using the diaphragm may reduce the risk of some STIs and if used with the male condom, provides added protection from pregnancy and STIs. The diaphragm is inexpensive. Disadvantages are that it is less eective than other methods, must be used with every act of intercourse, and is perceived as messy.

Emergency contraception Two forms of emergency contraception (or morning-after contraception) are available. There is only one dedicated product available in the United States, a high-dose progestin that may be used to prevent pregnancy for up to 5 days after an act of unprotected intercourse [46]. This high-dose progestin is most eective the earlier it is used and may prevent 87% of pregnancies. It is packaged as two pillsdthe rst taken as soon after unprotected intercourse as possible, the second taken 12 hours later. There is evidence that both tablets of this high-dose progestin may be administered as one dose with no decrease in ecacy [46]. Nausea and vomiting is unusual with progestin-only methods. This form of emergency contraception is thought to work primarily by preventing ovulation and will not disrupt an established pregnancy. It is over-the-counter for women over age 17 and requires a prescription for women aged 17 and younger. Discussing this form of emergency contraception should be routine for sexually active women using a method other than sterilization, implants, or an intrauterine device. Although this high-dose progestin is over-the-counter for most women, many are unaware of the medication. Education media campaigns, as well as individual physician-patient counseling, are needed to improve use of this form of emergency contraception. The older method of emergency contraception using combined oral contraceptive pills, known as the Yuzpe method, is not typically

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recommended because of its lower ecacy rate, lack of a dedicated product, and greater incidence of nausea and vomiting. Placement of a copper IUD is an even more eective postcoital contraceptive method that, when placed up to 7 days after unprotected intercourse, may prevent up to 99% of pregnancies. It also has the advantage that it may be maintained for long-term use and is ideal for the patient needing ongoing contraception [47]. Initiating contraception Internists may be in the position of deciding whether to initiate contraception or to refer to another physician. Ask about contraception: its an emergency! The rst step is simply to take a contraceptive history for every woman in the reproductive age range at every visit. Although women mostly visit internists for reasons unrelated to contraception, every visit constitutes a potential opportunity to make an impact on unintended pregnancy. Many women discontinue previously prescribed contraception without discussing the decision with a physician. If all reproductive aged women are considered at risk of pregnancy, the internist will identify at-risk women and initiate contraceptive counseling or make a referral. For the patient who desires intrauterine contraception, an etonogestrel implant, or permanent sterilization, specialized training is needed and unless the physician has such skills the patient should be referred in a timely fashion. However, for prescription hormonal methods, including the birth control pill, patch, and ring, the internist should consider initiating the method the same day. The clinician should also be prepared to provide information about barrier methods, such as condoms and sponges, as well as emergency contraception. Internists may even consider bridging women who desire a more permanent method with hormonal methods, if a delay to obtaining a more permanent method is anticipated. Given the epidemic of unintended pregnancy in this country, we should consider the woman sexually active with a man and not using contraception (or out of contraceptives) as a contraceptive emergency, and every eort should be made to provide an appropriate method immediately. Discuss methods or prescribe one: pills, patch, or ring In young healthy women without medical problems and who do not smoke, consider writing a prescription for pills, patch, or ring. A low dose (%35 micrograms of estrogen) generic, monophasic pill is an excellent standard pill to prescribe for contraception. Quick start is a method that may be adapted to expedite initiation [48]. In the true quick start method, the woman takes the rst pill under observation in the clinic. The pill may be

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prescribed, however, and the patient instructed to take the pill the same day. The pill may be initiated at anytime during the womans cycle. Seven days of a backup method are recommended before relying on the pills. Discussing condoms for STI prevention may also be helpful. Providers may be concerned that initiating a method can be harmful if a patient is already early in pregnancy. Sensitive pregnancy tests make this less likely, as they typically detect pregnancy 7 to 10 days after conception. Even if the patient is pregnant, hormonal methods including pills, patches, rings, DMPA, and single-rod implant, will not adversely aect the pregnancy. A Pap and pelvic examination are not required The tradition of bundling pill prescriptions with a Pap smear and a pelvic examination may lead to unintended pregnancy. The need for an oce visit may create a nancial barrier to contraceptive services. Additionally, adolescents may be intimidated by the need for a pelvic exam and forego contraception to avoid an exam. An internist may initiate pills without performing a pelvic examination or Pap smear that day. If the patient needs a Pap, it can be done that day, rescheduled to another day, or referral initiated if the physician does not perform Pap smears. Pregnancy prevention should not be made conditional on, for example, cervical cancer screening, an entirely unrelated service. In general, little is needed other than a medical history to initiate most methods. For hormonal contraceptives, major morbidity (which is quite rare) relates to patients risk for deep venous thrombosis, heart attack, and stroke. Risk factors are determined from history and rarely from physical examination. In addition to a history, a blood pressure determination and perhaps a pregnancy test are usually all that are required to initiate hormonal contraceptives. Other myths Oral contraceptives and other methods are plagued by myths that deter physicians from prescribing them and patients from using them. One such myth is that pills are generally unsafe and have many contraindications. In general, pills are quite safe with few contraindications and few true medical consequences (Box 1). Another common myth is that pills reduce the eectiveness of antibiotics, or vice versa. In fact, the only antibiotic that may reduce pill eectiveness is rifampin, an antibiotic reserved for specic circumstances and not commonly used. Similarly, many believe that anticonvulsants reduce the ecacy of hormonal contraceptives, an unlikely association. Although anticonvulsants may reduce the level of serum hormones, they have not been observed to be associated with increased incidence of ovulation or accidental pregnancy [37]. Women of reproductive age are often prescribed medications, such as angiotensin-converting enzyme inhibitors that are contraindicated in

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Box 1. Contraindications to oral contraceptive pill use Migraine headaches with focal neurologic signs Cigarette smoking in women older than 35 years History of thromboembolic disease Hypertension in women with vascular disease or older than 35 years Systemic lupus erythematosus with vascular disease, nephritis, or antiphospholipid antibodies Coronary artery disease Congestive heart failure Cerebrovascular disease including history of stroke
Data from Cook LA, Van Vliet H, Lopez LM, et al. Vasectomy occlusion techniques for male sterilization. Cochrane Database Syst Rev 2007;(2):CD003991.

pregnancy. It is important that all women of reproductive age be queried about their reproductive plans and oered contraception. Women who are planning pregnancy should be receiving focused counseling about medications that might adversely aect pregnancy. Women who are on potentially teratogenic medications should be given strong guidance about eective contraceptives, with encouragement to use a top tier method, such as an IUD or implant. Combination hormonal contraception may be safely continued until menopause in women without signicant cardiovascular risk factors, such as smoking or diabetes. The optimal way to transition women o combination hormonal contraceptives has not been studied. Women may transition either to no method or to hormone replacement therapy. A practical approach is to discontinue hormonal contraceptives at age 50 to 51, when the risk of spontaneous pregnancy is remote. If the patient continues to menstruate after discontinuing the contraceptives, she may restart the method for an additional year. If menses do not resume, no therapy is needed unless the patient has menopausal symptoms requiring treatment. Monitoring follicle-stimulating hormone levels is typically unhelpful, as decision making about perimenopausal hormone therapy is best based on clinical symptoms [37]. Summary The epidemic of unintended pregnancy in the United States is largely preventable with a combination of public health and medical measures. Although unintended pregnancy has declined over the last two decades, most would agree that a rate of almost 50% is unacceptably high. Unlike

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the cure for such complex diseases as cancer, the cure for unintended pregnancy is well known and could be implemented. Comprehensive sex education, accessibility to aordable long-term contraceptives, facilitation of procurement of ongoing prescribed contraceptives, and use of longterm forgettable methods are all strategies that could reduce unintended pregnancy and abortion in the United States. Internists are in a position to decrease the risk of unintended pregnancy for their patients. Asking all reproductive age women about their need for contraception and then providing a method or a timely referral could go a long way to decreasing the epidemic of unintended pregnancy in the United States. References
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