Gynecology IV CHAPTER 26 Contraception This chapter deals primarily with APGO Educational Topic Area: TOPIC 33 FAMILY PLANNING Students should be able to compare and contrast common contraceptive methods in terms of benefits, risks, mechanism of action, and effectiveness. They should be able to counsel a patient on options and identify barriers to effective contraception. CLINICAL CASE A young couple returns to your obstetric office for a routine postpartum visit after normal vaginal delivery of a healthy boy. Because of your explanation of the benefits of breastfeeding for mother and baby, the mother had elected to breastfeed despite discouragement from other professional friends.
With their confidence in you bolstered, the couple returns with a new, serious problem. They had planned to use condoms for contraception during breastfeeding, but now realize that the mother may breastfeed for a year or more and that they are not satisfied with the use of condoms, which distracts substantially from their sexual experience. They have never used a diaphragm, but feel it would present the same problems. As they plan to have more children, probably within the next 2 years, tubal ligation and vasectomy are inappropriate considerations.
They did an Internet search for the issues of hormonal contraception during breastfeeding and found themselves bewildered by the conflicting information they found. They seek your advice. 557 INTRODUCTION Over 50% of all pregnancies in the United States are unplanned, the highest rate in the developed world. Yet every year new contraceptive options are introduced touting various “improvements.” Although no method is effective if it is not used correctly, many methods are very reliable.
We will take a look at the various contraceptive options from the most reliable to the least and compare their risks, benefits, and reliability (their efficacy rate). Although there are many kinds of contraceptives, all work either by inhibiting the development or release of ova or blocking the meeting of ova and sperm. This goal is accomplished by two general mechanisms, each with many variations: (1) inhibiting the development and release of the egg (via oral contraceptive pills [OCPs], long-acting progesterone injection, or contraceptive patch and ring) and (2) imposing a mechanical, chemical, or temporal barrier between the sperm and egg (via condom, diaphragm, spermicide, intrauterine contraception, and fertility awareness). As a secondary mechanism, intrauterine devices (IUDs) placed as emergency contraception (EC) alter the ability of the fertilized egg to implant and grow.
It is important to understand that the mechanism of action of the IUD not placed for EC is via changes in the amount and viscosity of cervical mucus, endometrial suppression, inhibition of sperm migration and viability, changes in transport speed of the ovum, and damage to or destruction of the ovum. Each approach may be used individually or in combination and has its own advantages, disadvantages, risks, and benefits. Before helping any woman or couple choose among the many contraceptive options, the physician must consider two things. First, the physician must understand and be able to explain (in language the woman and partner can understand) the physiologic or pharmacologic mechanism of action of all of the available contraceptive methods, along with their effectiveness rates, indications, contraindications, complications, advantages, and disadvantages.
Second, the physician must know the woman and her partner well enough to recognize personal, physical, religious, or cultural values affecting the use of each contraceptive method under consideration and be able to help them deal with those issues using 558 empathic evidence-based discussions, regardless of any personal bias. When done correctly, these discussions allow the couple to understand the contraceptive options and the physician to freely provide evidence-based recommendations. In this manner, an appropriate individualized contraceptive method can be chosen whose correct, regular use is highly likely. Seen from another perspective, contraception allows the woman or couple to formulate a reproductive health plan, allowing conception to be a planned rather than an unexpected event.
This takes into account their desire for children and allows for planning the timing, spacing, and, ultimately, the optimal number of children. When comparing all contraceptive methods, both the typical use failure rate (the failure rate seen when the method is actually used by patients, that is, factoring in the mistakes in usage everyone will make from time to time and actual noncompliance) and method or perfect use failure rate (the failure rate inherent in the method if the patient uses it correctly 100% of the time) should be considered, as described in Table 26. Throughout the chapter, failure rates will be included in parenthesis (as typical/perfect use) referring to the percentage of unintended pregnancies within the first year of typical versus perfect use. By helping a woman and her partner choose a personally acceptable and biologically appropriate contraceptive method, the gap between the typical failure rate and method failure rate is minimized.1 CONTRACEPTIVE TECHNIQUE PREGNANCY RATES IN THE FIRST YEAR OF USE IN THE UNITED STATES Method Percentage of Women Experiencing an Unintended Pregnancy Within the First Year of Use Typical Usea Perfect Useb No method of 85.0 contraception Withdrawal 22 4 Hormonal contraceptives Combination pill 9 0.3 Progestin-only pill 9 0.05 contraceptive rods Barrier contraceptives Spermicides 28 18 Male condom 18 2 (without spermicide) Female condom 21 5 Diaphragm and 12 6 spermicide Sponge (parous 24 20 women) Sponge (nulliparous 12 9 women) IUDs Progesterone IUD 0.6 Natural family planning Standard days 5 method Two-day method 4 Ovulation method 3 Symptothermal 0.4 Permanent— sterilization Male 0.5 DMPA, depot medroxyprogesterone acetate; IUD, intrauterine device.
a Among typical couples who initiate the use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. b Among couples who initiate the use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. Adapted from the American College of Obstetricians and Gynecologists. Guidelines for 560 Women’s Health Care.
Washington, DC: American College of Obstetricians and Gynecologists; 2007:184–185. FACTORS AFFECTING THE CHOICE OF CONTRACEPTIVE METHOD Although efficacy is important in the choice of contraceptive methods, other factors to be considered include safety, availability, cost, acceptability, and, in some cases, the patient’s physical ability to appropriately use the method. Although we tend to think of safety in terms of significant health risks, for many patients, this also includes the possibility of side effects. Women may obtain good information from reliable sites on the Internet, but there is also a huge amount of incorrect or biased information that can complicate the discussion between the physician and patient.
Because good information empowers good decision making, and the converse is also true, physicians must take the time to explain the information brought in by patients. The Centers for Disease Control and Prevention’s Medical Eligibility Criteria for Contraceptive Use (http://www.gov/reproductivehealth/contraception/usmec.htm) is a useful resource for patient counseling. How and when the method is used can also determine the acceptability. Options vary from methods that are coitus dependent (barriers) to methods that are placed by a health-care provider and last for up to 10 years (intrauterine contraception).
Some women prefer methods they control. They can choose an oral daily preparation, whereas others consider the weekly transdermal (contraceptive patch) or the monthly transvaginal (contraceptive ring) forms easier to use successfully. Other women elect to use a method administered by their physician such as injections, implants, and intrauterine contraception. Methods that are not user or coitus dependent tend to be more effective.
Sterilization (permanent contraception) is discussed in Chapter 27. Career or other life choices, as well as plans for future fertility, may influence the type and duration of the method chosen. Additionally, the couple’s feelings about which partner should take responsibility for contraception may be important. Finally, the ability of a contraceptive method to provide some protection against sexually transmitted diseases (STDs) may also be 561 relevant, but the physician must explain that such protection is not the main intended use of most contraceptives.
Helping patients understand that, aside from condoms, contraceptive methods do not provide protection from STD is one of the most important preventive care tasks. The physician must be sensitive to all factors that might influence the decision and provide factual information that fits the needs of the woman and her partner. All practitioners should guard against imposing their own cultural or religious bias into the discussion. A decision tree based on this concept is presented in Figure 26.2 offers a view of the multiple options.
Decision tree for choosing a contraceptive method. IUD, intrauterine device; LARC, long- acting reversible contraception; LNG, levonorgestrel; OCP, oral contraceptive pill.2 TYPES OF CONTRACEPTIVES 563 From U. Food & Drug Administration. Birth Control Guide.
Retrieved from https://www.gov/downloads/ForConsumers/ByAudience/ForWomen/FreePublications/UCM517406.pdf LONG-ACTING REVERSIBLE CONTRACEPTION 564 Long-acting reversible contraception (LARC) can offer contraceptive efficacy equal to or better than permanent sterilization with the advantage of reversibility. In that respect, they are ideal for timing and spacing pregnancies. Additionally, they have few contraindications and the risks and side effects are low. Implantable Hormonal Contraceptives (0.05%) The implantable contraceptive system is a 4-cm by 2-mm rod containing a progestin (etonogestrel) that provides 3 years of contraception.
With a typical and perfect use failure rate of 0.05%, it is the most effective form of contraception available, including female sterilization (0. The implant works primarily by thickening the cervical mucus and inhibiting ovulation. Insertion and Removal Insertion is a simple office procedure under local anesthesia. A special applicator is used to place the rod “just underneaththe skin.” The procedure takes less than a minute with minimal discomfort (Figure 26.
Postpartum insertion may be performed while the patient is still in hospital and decrease the risk of pregnancy that is accompanied by missed postpartum visits. Subcutaneous contraceptive implant using etonogestrel (Nexplanon). Removal of the device is also performed in the office under local anesthesia. Although it requires a small (2 mm) incision, it is also well tolerated.
In addition, a new implant may be placed at the same time for 3 more years of highly effective contraception. Side Effects The most common side effect is irregular, unpredictable vaginal bleeding that may continue even after several months of use.6%) Intrauterine contraceptives, also known as IUDs or intrauterine contraception devices, are recommended for adolescent, nulliparous, and parous women and are among the most commonly used and safe methods of interval contraception worldwide. However, in the United States oral contraceptives and sterilization are more common despite lower efficacy. This continued disinterest in IUDs stems from early kinds of IUDs that were associated with an increased incidence of pelvic inflammatory 566 disease (PID) and infertility.
These devices were removed from use and the current IUDs are not associated with PID. Nonetheless, the fear continues to dissuade some women, and practitioners, from IUD use despite the proven safety profile of the current models. There are four IUDs available in the United States—three hormonal and one nonhormonal. All are T shaped.
The hormonal IUDs release a small amount of levonorgestrel (LNG-IUD) into the uterus (0.2%), and the nonhormonal IUD releases a small amount of copper (Cu-IUD) into the uterus (0. Insertion IUD insertion is best accomplished when the patient is menstruating. This timing is beneficial because it confirms the patient is not pregnant and her cervix is usually slightly open. If that timing cannot be achieved, it can be done at other times in the cycle as the patient is switching from another reliable method of contraception.
The devices may also be inserted in breastfeeding women, who, in fact, demonstrate a lower incidence of postinsertional discomfort and bleeding. All IUD insertion techniques share the same basic rules: careful bimanual examination before insertion to determine the likely direction of insertion into the endometrial cavity, proper loading of the device into the inserter, careful placement to the fundal margin of the endometrial cavity, and proper inserter removal while leaving the IUD in place (Figure 26.