Contraception Winter 2017

Contraception Variety of methods Categorized by methodology Barriers Hormonal methods Fertility awareness methods Sterilization Contraceptive issues vary across countries Contraceptive methods in the U.S. (Guttmacher Institute, 2012) Under Affordable Care Act, rate for uninsured women reduced 1/3 Contraceptive methods in the U.S., 1995 vs. 2006-10 (CDC) Contraceptive prevalence (Excel, pdf map) across the world (United Nations, 2012) Contraceptive prevalence by method (WHO, 2015; page 10, Figure 4), or prevalence by method (United Nations, 2011)

Why Does Contraception Matter? We (taxpayers) pay for many unexpected pregnancies Rates of unintended pregnancy (Guttmacher Institute) How much (Guttmacher Institute) Youth comparisons in Germany, France, Netherlands (Advocates for Youth) Adolescent Fertility Rate (World Bank)

Contraceptive Issues You Decide

Contraceptive Issues Effectiveness against pregnancy Side effects Potential unidentified effects of contraceptive use over the long term Cost Religion Interactions with other medications Sexually transmitted infection protection Convenience Reversibility Length of effectiveness Benefits outside of contraception (e.g. using hormone-based contraception to regulate menstrual cycle, reduce menstrual pain, reduce heavy menstrual bleeding, reduce menstrual migraine)

Contraceptives – How They Work Dependent Upon Category Barriers Hormone-Based Methods Sterilization Fertility Awareness Methods

Contraceptives – How They Work with Anatomy & Physiology

Sterilization

Sterilization Sterilization = permanent contraception Women undergo tubal ligation or implant Men undergo vasectomy The second most common contraceptive method used in the United States (men’s and women’s methods combined) No formalized data collection system exists Data retrieved from surveys, questionnaires Female sterilization: 700,000/year (emedicinehealth.com) Vasectomies: 500,000/year (WebMD)

Sterilization: Vasectomy Vasectomy blocks sperm from traveling through the vas deferens, preventing sperm from mixing into semen No glands or organs are removed Effectiveness: 99%+ Considered irreversible

Sterilization: Vasectomy Vas deferens must be isolated The vas deferens can be cut and tied, clamped, cauterized, no scalpel technique Another form of contraception must be used for a few months

Sterilization: Vasectomy Cost: $0-1000 (plannedparenthood.com) Not currently covered via Affordable Care Act Planned Parenthood may provide no- or low-cost vasectomies; state plans may offer benefit (Oregon, e.g.) Side effects: bruising, sensitivity/pain, sperm leaking from tubes may lead to small lump (usually clears up on its own), antibodies to sperm may develop, reducing chances of fertility in a reversal Complications: rare, usually associated with infection (fever, pus/blood from incision site, swelling, pain); ends of tubes may grow back together (very rare); decreased sexual desire (4 out of 1000 cases per Planned Parenthood) - no apparent physical cause

Sterilization: Vasectomy Animation (BUPA Health via YouTube, 2:36) Video (vasectomymedical.com) Vasectomy (vasovasostomy) reversal video (Vimeo.com, 4:00)

Sterilization: Tubal Ligation Surgical technique Animation (1:35+) Close fallopian tubes, preventing egg from traveling to uterus, preventing sperm from reaching egg Neither organs nor glands are removed Effectiveness: 99%+ Considered irreversible

Sterilization: Tubal Ligation Tubal sterilization: Tubes can be tied and cut (Pomeroy technique) Tubes can be cauterized Tubes can be clipped, clamped These incision methods often performed after childbirth/abortion

Sterilization: Tubal Ligation Cost: $0-3000 Side effects: thought by many to be rare; hormonal imbalance may lead to increased menstrual bleeding, cramping; adhesions Complications: infection, internal bleeding, ectopic pregnancy Before/after photos (private Flickr account)

Sterilization: Implants Non-incision method No general anesthesia Under an hour Coils inserted into fallopian tubes In following months, coils and tissue grow together, forming barrier to prevent sperm from reaching egg

Sterilization: Implants Side effects: expulsion of coil inserts, risk for ectopic pregnancy, cramping, menstrual changes, nausea/vomiting Animation (YouTube) Thousands of complaints regarding implant complications reported to FDA (NY Times, 2015)

Intrauterine Contraceptives (IUC’s) IUC’s are made of flexible plastic, available only through prescription Two types (U.S.) ParaGard (copper-based IUC) Hormone-based IUC’s Mirena Skyla Liletta Kyleena

IUC’s: ParaGard ParaGard contains copper Copper prevents sperm from fertilizing an ovum Appears to be disagreement on whether ParaGard also causes inflammatory response in uterine cavity Copper may also affect the ovum, reducing its ability to become fertilized (Medscape) Amount of copper released is less than needed in daily diet Copper intolerance or insensitivity would preclude use of ParaGard

IUC’s: Paragard Requires insertion into uterus by healthcare provider Takes only a few minutes Insertion may cause cramping, dizziness Once inserted, may remain in place for ten years Patient should not feel IUD Since no hormones present, monthly cycle should remain unchanged Insertion video Effectiveness: 99%+ against pregnancy Requires monthly checking for IUD slippage

IUC’s: ParaGard Side effects: heavier and longer periods, cramping, spotting in between periods May lessen after a few months on ParaGard Complication risks: pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion Copper may provide protective benefit against endometrial cancer Cost: $0-1000 (Planned Parenthood)

Hormone IUC’s: Mirena Hormonal method (pregestogen) Intrauterine device Lasts for five years Mirena: Prevents sperm from fertilizing ovum Prevents release of egg Changes uterine lining

Hormone IUC’s: Mirena Insertion: Similar to ParaGard Effectiveness: 99%+ against pregnancy Cost: $0-1000 (Planned Parenthood, Bedsider.org) Side effects: Abdominal cramping (10% of users during first few months), acne, breast tenderness, headache, mood changes, back pain May lessen after a few months As use continues, less menstrual bleeding Complication effects: ovarian cysts, pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion

Other Hormone—Based IUD’s Skyla Liletta Kyleena Differences (table 1, kff.org) Effectiveness timeframe Amount of progestin (Picture = Skyla & Mirena)

IUC’s Internal Birth Control- IUD’s (via Youtube) Insertion of IUC (Medialvideos.us)

Barrier Contraceptive Methods Physical barriers Prevent sperm from entering cervix Block sperm from fertilizing ovum

Barrier Contraceptive Methods Historically, pessaries used Objects or substances inserted into vagina Pregnancy prevention effectiveness Infection effectiveness Current barrier methods: spermicide, male condom, female condom, diaphragm, cervical cap, sponge

Contraceptive Barriers Barriers generally have less effectiveness against pregnancy than sterilization, IUC’s, hormone contraceptive methods Of all contraceptive methods, two barriers provide the greatest protection against sexually transmitted infections External (“male”) condom Internal (“female”) condom Public domain image, created by Villy Fink Isaksen, was downloaded from Wikimedia Commons

External (“Male”) Condom Available over the counter in many colors, types, sizes, with & without lubricant Placed on an erect penis Prevents ejaculate from entering vagina Also used to prevent infection transmission New condom for each act of intercourse Expiration date Typical effectiveness: 85-90%, “perfect use: 95% Used for anal sex, but not FDA approved for that purpose Public domain image at left was taken by ClaudiaM1FLERéunion, and downloaded via Wikimedia Commons

External (“Male”) Condom Most are latex, free-$1 per condom in U.S. Some are polyurethane May transfer heat better than latex More likely to break vs latex (7.2% vs 1.1% in Guttmacher Institute reference) More expensive, ~$1+ Polyisopropene Latex-like without latex Lifestyles and Durex brands, ~$0.50+ Lambskin Sheep intestinal membrane Less effective against infection transmission (~$3) Kitemark Condom Testing (National Geographic)

Internal (“Female”) Condom FC2 nitrile condom, available over the counter Two rings: closed, open ends Inserted prior to intercourse, up to several hours Prevents ejaculate from reaching vagina Cost: $1.25-4 per condom New condom for each act

Internal (“Female”) Condom Effectiveness: ~80% typical, 95% “perfect” (Planned Parenthood) Animation Used for anal sex, but not FDA approved for that purpose

Barriers: Spermicide & Nonoxynol-9 Spermicides inserted before vaginal intercourse, to stop sperm movement Nonoxynol-9 is ingredient in spermicides Nonoxynol-9 originally designed to protect against HIV In last 20 years, opposite appears to be reality Among commercial sex workers in Africa, Thailand Frequent use Nonoxynol-9 may increase risk for disease transmission Increases vaginal irritation, which can lead to lesions/sores Lesions typically result in disease transmission vulnerability Concern continues (Smith-McCune, et.al., PLOS One, 2015) FDA requires manufacturers to provide warning

Contraception: News, Interesting Info Caya – new diaphragm, 2015 (0:30-2:35, product website) Silk Parasol (path.org, Silk Parasol via product website) Proposed panty condom in Uganda (monitor.co.ug, 2015)

Contraception: The Past Male Contraceptive: Heat Prolonged heat exposure can impair sperm production in testes Ancient method Effectiveness? Research by Voegeli in 1940’s: 116 degree bath 45 minutes Every day Three weeks Six months of sterility

Contraception: Impact of Heat on Sperm

Contraception: Impact of Heat on Sperm Upper left: coiled tail Upper right: bent tail Lower left: double head Lower right: triple head Dada, R, Gupta, NP, & K. Kucheria. Deterioration of Sperm Morphology in Men Exposed to High Temperature. Journal of the Anatomical Society of India. Vol. 50, No. 2 (2001-07-2001-12)

Contraception Hormonal Methods

Hormonal Contraceptives: Mechanism of Action Synthetic estrogen and/or synthetic progesterone Combination hormone contraceptives halt ovulation (release of egg) No egg = no pregnancy HybridMedical video: Ovulation (YouTube)

Hormone-Based Contraception Estrogen Usually ethinyl estradiol Progestin Many types Types vary in terms of side effects Blood lipids Break-through bleeding Weight gain/metabolism Acne Source: Dawn Stacey, About.com

Estrogen Estrogen suppresses development of follicle within ovary Estrogen changes the endometrial lining, making the uterine environment less accommodating to a fertilized ovum

Estrogen Estrogen makes progestin activity stronger Progestin manipulates one of the hormones responsible for ovulation So, even if estrogen does not completely prevent follicle development, it works with progestin to prevent ovulation

Progestin Progestin thickens cervical fluid (cervical mucus) Thicker fluid hampers sperm movement Progestin also changes the endometrial lining in uterus Reduces likelihood for egg implantation Progestin-only methods may not inhibit ovulation Varies from one cycle to another Method dependent (Depo-Provera inhibits ovulation, minipills may not) Effectiveness due to cervical fluid, endometrial changes

Bottom Line: Estrogen & Progestin Roles in Hormonal Contraception Hormonal contraceptive methods work to prevent ovulation Hormonal methods thicken cervical fluid to make sperm transport difficult Hormonal contraceptive methods change the lining in uterus to make fertilized egg implantation difficult

Hormonal Contraceptives Side Effects Estrogen effects Progestin effects Androgen effects

Hormone Contraceptive Side Effects Estrogen: Hypertension, headache, breast fullness, irritability, nausea, vomiting, bloating, breakthrough bleeding Progestin: Headache, breast tenderness, hypertension Androgenic: Acne, weight gain, hair growth, fatigue, depression Each person is different, so the above effects are guidelines Chart (Dawn Stacey, about.com) Side effects may change if the problem is dose-related Source: Carl Rice, et.al., Selecting and Monitoring Hormonal Contraceptives: An Overview of Available Products, U.S. Pharmacist; 6: 62-70

Hormone Contraceptive Contraindications (especially combination methods) Women 35 years and older who smoke Women with history of cardiovascular issues should avoid estrogen Epilepsy, if using specific medications Obesity may be related to effectiveness issues (consider IUC) Certain bariatric procedures Migraine headaches Breast cancer Cervical cancer STI if using IUD This list not exhaustive Reproductiveaccess.org chart

Hormone Contraceptive Benefits Regulation of menstrual bleeding Reduced risk of ovarian, uterine cancer Reduced menstrual pain (pills, implant) Control of excess hair growth Reduced acne

Patch OrthoEvra, Xulane (generic) Beige plastic patch applied to the skin Once a week for three weeks Stomach, upper arm, upper torso, buttocks First day of menses or first Sunday after period starts Releases estrogen and progestin Effectiveness: 99% Cost: $0-80/month (Planned Parenthood) No STI protection Some may have reaction to adhesive

NuvaRing Insertion of ring into vagina Remains in place for three weeks Releases estrogen and progestin Cost: $0-80/month (Planned Parenthood) Insertion (YouTube, 0:45-1:20) Effectiveness: 99%+ No STI protection

Nexplanon/Implanon Nexplanon most recent version (easier insertion/removal) A single implant in the upper arm Progestin-only method Works for three years (up to four) Effectiveness: 99%+ Cost: $0-800 (Planned Parenthood) No STI protection Sensitive Implanon insertion video (YouTube, 2:08) https://www.youtube.com/watch?v=Y4Tqu1X7cfY Sensitive Nexplanon insertion video (YouTube, 0:39)

Depo-Provera/Depo-subQ Provera 104 (“Depo”) Progestin-only Hormone injected every three months Arm Buttocks Cost: $0-100 per shot plus exam fees Effectiveness: 94% No STI protection ”Black box” warning for increased osteoporosis risk

Contraceptive Pills Chewable pill (Femcon Fe) - discreet; also helps when swallowing pills is difficult Continuous cycle pills (Seasonique, Amethyst) – no placebo pills Natazia – estradiol valerate used instead of ethinyl estradiol

Emergency Contraception Available over the counter A variety of pills Copper IUD No age restrictions Source: Emergency Contraception, Princeton University

Fertility Awareness Methods No prescriptions, contraceptive purchases required Methods track ovulation Strategy: if sperm are not near egg when it is released, fertilization cannot occur Ovum lives for ~24 hours after being released Sperm can live for ~6 days Pregnancy chances ~7 days out of cycle (five days before ovulation plus 1-2 days after) Image by Dafne Cholet, via Flickr

Fertility Awareness Methods - Effectiveness Generally, 75-80% effectiveness, with perfect use, up to 95%, depending upon methods (outside of abstinence) used “Effectiveness” - based on pregnancies among 100 male-female couples engaging in vaginal intercourse for one year Effectiveness can increase when using more than one FAM, or additional non-FAM contraceptives No sexually transmitted infection prevention

Abstinence No “sex” What does this mean? Effectiveness depends on interpretation of term

Withdrawal During vaginal intercourse, penis is removed from vagina before ejaculation “Coitus interruptus” “Pull-out” method

Temperature Method Track temperature every morning Look for slight drop in temperature occurring immediately before ovulation At ovulation, small temperature (.1 degree) increase Track for three months, every morning, before relying on method Use chart to look for trends, expect daily fluctuations Tracks when ovulation has happened, but cannot be used to predict ovulation

Temperature Method Day 10: 98.5 Day 17: 98.8 Day 11: 98.4 Day 18: 99.0

Calendar Method Use monthly cycles to predict “safe” and “unsafe” days Calendar, app, website tool Count cycle days Day #1 = first day of menses Last day = day before menses returns Count for eight cycles before use If all cycles <27 days, don’t use Subtract 18 from shortest cycle Subtract 11 from longest cycle Apply to calendar

Calendar Method Cycle 1: 25 Cycle 2: 27 Cycle 3: 28 Cycle 4: 28 Shortest day: 25 Longest day: 29 Unsafe days: #7-18

Symptothermal, Standard Days Methods Symptothermal: combination of calendar, temperature, and cervical fluid/mucus monitoring Standard Days method: uses specific “CycleBeads” tool to track CycleBeads App (YouTube)

Fertility Awareness Contraindications Irregular cycles Multiple partners Sexually transmitted infections (discharge) Unable to abstain on “unsafe” days Adolescence, breastfeeding, menopause Use after hormone-based contraceptive, at least for several months