Contraception

Rushelle A. Jones M.D.

University of Tennessee College of
Medicine, Department of OB/GYN
 CREOG Objectives
z Describe the factors that influence an individuals
choice of contraception
z Elicit a pertinent history in a patient requesting
information about contraception
z Describe the advantages, disadvantages, failure
rates, and complications associated with the
following methods of contraception
– Sterilization
– Oral steroid contraception
– Injectable steroid contraception
– Implantable steroid contraception
– Barrier methods
– Natural family planning
 Abstinence
z Mechanism: excludes sperm from female
reproductive tract
z Effectiveness: 0% failure rate
z Ideal for adolescents at high risk for
pregnancy and STD’s including HIV
z Complications: recent data have shown an
increase in teen sexual activity and
pregnancy if no education is given on
contraception
 Breastfeeding: Lactation
Amenorrhea Method (LAM)
z Mechanism: Suckling causes increased prolactin,
which inhibits estrogen production and ovulation
z 2% typical use failure rate in 1st six mos.
z Candidates:
– Amenorrheic women < 6 mos post-partum who
exclusively breastfeed (90% of nutrition is breast milk)
– Women free of blood-borne infections
– Women not on drugs that could effect baby

Kennedy KI. et al., Contraceptive Technology.2004

 LAM Complications
z Breastfeeding may increase the risk of
mastitis
z Return of fertility or ovulation may precede
menses.
z 33-45% ovulate during 1st 3 mos.
z Encourage backup form of contraception as
average duration of breastfeeding in the
U.S. is 3 months.
 Barrier Methods: Male
Condoms
z Sheaths of latex, polyurethane, or natural membranes
that may or may not have spermicide
z Mechanism: Barrier that prevents sperm and infections
from entering vagina
z Effectiveness: 15% typical use failure rate
z Candidates:
– Couples not in mutually monogamous relationships
– Couples in which one partner has an STD/HIV
– Couples starting other types of birth control
– Couples who can’t use hormonal methods

Warner DL, et al. Contraceptive Technology. 2004

 Barrier Method: Female
Condom
z Disposable single use polyurethane sheath
placed in vagina
z Flexible movable inner ring at closed end used
to insert into vagina
z Flexible outer ring to cover part of the introitus
z Mechanism: Prevents passage of sperm and
infections into the vagina
z Failure rate is high at 21% with typical use

Hatcher et al. Managing Contraception.2004

 Barrier Method: Female
Condom
z Candidates the same as for male condoms
z Female condom is reusable only if the
partner does not have an STD
z Disadvantages:
– Awkward and difficult to place
– Most users do not enjoy using female condom
(88% of women and 91% of men)
– Many couples complain about noise of condom
 Barrier Method: Cervical Cap
z Thimble- shaped latex rubber device which has an
inner ring that provides suction to keep cap on the
cervix
z Spermicide is placed inside the cap before being
placed on the cervix to kill sperm
z 4 sizes: 22, 25, 28, 31 mm
z Mechanism: barrier that prevents sperm migration
into cervical canal

Gordon et al. Handbook for Clinical Gynecologic Endocrinology and Infertility.2002

 Barrier Method: Cervical Cap
z Advantages:
– May decrease risk of GC, Chl, and PID
– Can be placed 6 hours prior to intercourse
– Can remain in vagina up to 48 hours for
multiple acts of intercourse
z Disadvantages:
– No protection against HIV
– Poor fit especially in parous women
– Failure Rate: As high as 32% in parous women
and 16% in nulliparous women
– Patient must leave in place at least 8 hours after
intercourse before removing
 Barrier Method: Diaphragm

z Latex rubber dome-shaped device that

covers the cervix
z Mechanism: prevents sperm from entering
cervical canal
z Three types:
– Arcing Spring
– Coil Spring
– Wide Seal
 Barrier Method : Diaphragm
z Typical use failure rate: 16% in one year
z May reduce risk of GC, Chl, PID
z Risks:
– No protection from HIV
– Difficult to place around cervix
– May fall out in women with pelvic relaxation
– May cause vaginal erosions & infections
– May cause reaction in latex allergic
– Toxic Shock Syndrome
– Urinary Tract Infections
 Spermicide
z Most common is nonoxynol-9
z Available in creams, films, foams, gels,
suppositories, sponges, and tablets
z Best when used with barrier methods
z 29% typical use failure rate when used
alone
z Provides no protection against STD’s and
HIV
 Emergency Contraception
(EC)
z Any method used after unprotected or
inadequately protected sexual intercourse
z Three types of EC available in the United States:
– High dose progestin only ( Plan B)
– Yuzpe method- 13 different combined oral
contraceptives (Preven)
– Copper IUD ( Paragard)

Dickey. Managing Contraceptive Pill Patients, 2002

 Emergency Contraception
(EC)
z Mechanism: Prevents fertilization and
implantation. Counsel patients that this
method does not abort a pregnancy that is
already implanted
z Common in women after an assault or rape
z Most women will have a cycle 21 days after
completing emergency contraception
z If patient does not have a cycle in 21 days,
it is important to check a pregnancy test
 Emergency Contraception
(EC)
z High dose progestin-only (Plan B):
– 1.5mg Norgestrel at one time or in divided doses.
– Divided Dose: 1st dose within 72-120 hours of
intercourse. 2nd dose 12 hours later.
– One dose: Both tablets within 72-120 hours of
intercourse

Glaser A. Emergency post-coital contraception, New England Journal of Medicine, 1997.

 Emergency Contraception
(EC)
z Yuzpe Method (Preven)

– 100mcg of ethinyl estradiol and 0.50 mg of

levonorgestrel in each dose.
– 1st dose within 72 hours of intercourse and 2nd
dose 12 hours later
 Emergency Contraception
(EC)
z Copper IUD
– Place within 5 days of unprotected coitus
– This is usually given to women who plan to use
the IUD for long term birth control
– Interferes with implantation after fertilization
 Intrauterine Devices (IUDs)
z CopperIUD
(Paragard T 380 A)
– Copper is a spermicide
that inhibits sperm
motility and
acrosomal enzyme
action
– Lasts 10-12 years
– May increase bleeding
and dysmenorrhea
– Typical use failure
rate is 0.8%
McGavigan et al. Drugs Today. 2003
z Mirena(Levonorgestrel)
– Increases thickness of
cervical mucus to inhibit
sperm migration
– Lasts up to 5 years
– Improves menorrhagia
by 90% in most patients
– Causes amenorrhea in
many users
– Typical use failure rate
is 0.1%
 IUD
z Good for women in mutually monogamous
relationships
z Risks:
– Increased risk of PID within 1st 20 days
– Uterine perforation
– Fainting with insertion
– Expulsion
– Unexpected pregnancy following poor placement

www. mirena .com

 Combined (Estrogen &
Progestin) Contraceptives:
Oral
z Mechanism:
– Blocks ovulation
– Thickens cervical mucus
– Thins the endometrial lining
 Combined (Estrogen &
Progestin) Contraceptives:
Oral
z Ethinyl estradiol is the most commonly
used estrogen in OCP’s
z There are multiple forms of progestins
z Monophasic: same amount of hormone in
each active tablet
z Multiphasic: varying amounts of hormone
in each active pill
z Most OCP’s have 21 active pills and 7
placebo pills
 Combined (Estrogen &
Progestin) Contraceptives:
Oral
z Alternate Formulations:

– Mircette: 21 active pills, 2 days of placebo,

and 5 days of 10 mcg ethinyl estradiol alone
– Seasonale: 84 consecutive hormonal pills
followed by 7 days of placebo
– Ovcon-35: chewable pills
– Yasmin: Drospirenone which is anti-
androgenic and anti-mineralcorticoid
 Combined (Estrogen &
Progestin) Contraceptives: Oral
z Advantages: z Disadvantages
– Improves acne
– Improves menorrhagia
– Decr. Dysmenorrhea
– Regulates cycle in
anovulatory women
– 50% reduction in
ovarian ca. with 5 year
continuous use. 80%
reduction over 10 years
– Reduces endometrial
ca
– Decr. Benign breast dz.
– Spotting especially in
1st few months
– May decr. libido
– Requires daily pill
intake
– No protection against
STD’s and HIV
– Possible weight gain
– Post-contraception
amenorrhea
 Contraindications Combined
(Estrogen & Progestin)
Contraceptives: Oral
z Absolute Contraindications:
– History of thromboembolism, MI, stroke
– Impaired liver function
– Known or suspected breast cancer
– Undiagnosed abnormal vaginal bleeding
– Known or suspected pregnancy
– Smokers over age 35 ( may use progestin-only
pill)

Gordon et al. Handbook for Clinical Gynecologic Endocrinology and Infertility.2002

 Contraindications Combined
(Estrogen & Progestin)
Contraceptives: Oral
z Relative Contraindications
– Migraine headaches
– HTN- ok if <35, or healthy, or BP controlled
– Elective surgery: Discontinue 4wks. prior to major
surgery
– Gallstones/ Cholecystitis
– Epilepsy: anti-seizure meds may decrease effectiveness
of OCP’s
– Diabetes: small risk or worsening vascular dz.

Gordon et al. Handbook for Clinical Gynecologic Endocrinology and Infertility.2002

 Choosing The Right OCP’s
z Endometriosis: Choose a pill with a strong
progestin to create a pseudo-pregnancy state
z Functional Ovarian Cysts: High dose
monophasic pill may be more effective
z Androgen excess: Choose a pill with high
estrogen/progestin ratio to reduce free testosterone
and inhibit 5α reductase activity
z Breastfeeding: Progestin -only pill
 Transdermal: Ortho Evra
z Delivers 20 mcg of ethinyl estradiol and 150
mcg of norelgestromin daily
z Takes 3 days to achieve a steady state of
hormone in the blood stream
z Patch is replaced once per week for 3
consecutive weeks
z Worn on abdomen, buttocks, upper outer arm,
or upper torso
z Do not place on the breast

www.aafp.org
 Transdermal: Ortho Evra
z Advantages:
– Only has to be replaced once per week
– May be taken continuously
z Disadvantages:
– May slip off- provide pt. with an emergency
patch
– Patch may be less effective in women who are
> 198 pounds
 Vaginal Contraceptive Ring:
NuvaRing
z Combined hormonal contraception consisting of a
5.4 cm diameter flexible ring
z 15 mcg ethinyl estradiol and 120 mcg of
desogestrel
z Mechanism: suppresses ovulation
z Typical use failure rate: 8%

Szarewski,A. Euro Journal of Contraception. Reproductive. Health Care. 2003

 Vaginal Contraceptive Ring:
NuvaRing
z Place in vagina and remove after 3 weeks
z Allow withdrawal bleeding and replace new
ring
z Steady low release state
z Advantage is patient only has to remember
to insert and remove the ring 1x/ month
z May be placed anywhere in the vagina

www.nuvaring.com
 Depo Provera
z 150 mg IM every 3 months
z Contraceptive level maintained for 14
weeks
z Failure Rate: 3% typical use failure rate
z Mechanism:
– Thickens cervical mucus
– Blocks the LH surge
– Initiate treatment during the first week of
menses
 Depo Provera
z Advantages z Disadvantages
– Long acting
– Estrogen-free
– Safe in breast-feeding
– Can be used in sickle-
cell disease and seizure
disorder
– Pt. does not have to
take daily
– Increases milk quality
in nursing mothers
– Irregular bleeding
(70% in first year)
– Breast tenderness
– Weight gain
– Depression
– Slow return of menses
after stopping use
– Decreases HDL
cholesterol
 Male Sterilization
z Vasectomy: ligate or cauterize the vas deferens
z Mechanism: interrupts vas deferens preventing
passage of sperm into seminal fluid
z May be done under local anesthesia
z Cheaper than female sterilization
z Failure rate: < 0.15%
z Use contraception until completely azospermic for
two consecutive sperm counts ( usually takes 12
weeks or 10-20 ejaculations)
z Does not affect ability to have an orgasm
 Female Sterilization
z Interrupts the patency of fallopian tubes-
thereby preventing fertilization
z Failure rate: Depends on method used -
ranges from 0.8-3.7%
z May be performed through a mini-
laparotomy incision , laparoscopically, or
transcervically
 L/S Sterilization
z Performed as outpatient

z Bipolar Cautery: bipolar cutting current of 25

watts to cauterize the tube

z Falope Ring: silastic band that ligates a knuckle

of tube

z Hulka clip: spring-loaded clip applied to isthmic

portion of the tube

z Filshe: titanium with silicone rubber clip applied

to isthmic portion of the tube
 Mini-lap Sterilization
z Modified Pomeroy
z Modified Parkland
z Irving
z Uchida
z Fimbriectomy

z Transcervical: Essure is a mesh-like substance

that irritates the tube and causes scarring that
blocks the tube. Complete scarring takes about 3
months.
 Coming Up…
z Protectaid- New vaginal sponge under
investigation

z Implanon: Single rod implant to replace the

Norplant
 Bibliography
1. Gordon, John. Handbook for Clinical Gynecologic Endocrinology and Infertility,
2002.
2. Hatcher, Robert et al. Managing Contraception, 2004-2005.
3. Dickey, Richard. Managing Contraceptive Pill Patients,2000.
4. The American College of Obstetricians and Gynecologists Compendium, 2004.
5. Kennedy, KI. et al. Postpartum contraception and lactation. IN Hatcher RA, Trussell
J, Stewart F et al: Contraceptive Technology, 17th edition; New York: Ardent Media
Inc.; 1998:592-4
6. Warner L, Hatcher RA, et al. Male condoms, IN Hatcher RA et al. Contraceptive
Technology. 18th edition. 2004
7. Glasier A: Emergency post-coital contraception. New England J Med.1997;
337:1058-1064
8. Szarewski, A. Euro J Contraception Reproductive Health Care. 2002
9. www.nuvaring.com
10. www.aafp.com