Contraception Winter 2019

Outline Hormone Methods How estrogen works, how progestin works Combination vs progrestin only Pills Combination Minipills Patch Ring IUD – Mirena, Skylla, Kyleena, Liletta Shot Implant Newer hormone methods? Annovera ring – combined method; works for a year

Contraceptive Issues Effectiveness against pregnancy Side effects, including allergies Cost Availability Durability Sexually transmitted infection protection Future plans for pregnancy, including reversibility of method Duration of effectiveness Age-based barriers

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

Contraceptives – How They Work with Anatomy & Physiology

Hormone Contraceptive 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)

Estrogen Usually ethinyl estradiol Estrogen manipulates hormones to suppress development of follicle within ovary Estrogen changes the endometrial lining, making the uterine environment less accommodating to a fertilized ovum Estrogen supplements progestin activity

Progestin Many types of progestins Progestin thickens cervical mucus Thicker mucus 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 mucus, endometrial changes

Bottom Line: Estrogen & Progestin Roles in Hormonal Contraception Hormonal contraceptive methods work to prevent ovulation Hormonal methods thicken cervical mucus to make sperm transport difficult Hormonal contraceptive methods change the lining in uterus to make fertilized egg implantation difficult Video (2:10-3:30, Manipal Hospitals, via YouTube)

Hormonal Contraceptives Side Effects Varying levels of estrogen and progestin can influence effects Varying types of progestin can influence effects Estrogen –cardiovascular effects, headache, weight gain; interfere with milk production; smokers at much higher CV effect risk Progestin – fewer CV effects, more irregular and break-through bleeding (spotting); influence on mucus and endometrium = consistency is important Chart (Dawn Stacey, about.com)

Contraceptive Patch Xulane Applied once a week for three weeks Stomach, upper arm, upper torso First day of menses or first Sunday after period starts Combination method: estrogen and progestin If detaches for less than a day, apply a new patch; if more than a day, apply new patch and begin new cycle Cost: $0-150 (Planned Parenthood)

Contraceptive Patch Patch should be applied on same week day Cost: Included with insurance; average wholesale price is ~$0-150/month plus exam (Planned Parenthood) Available via physician, Planned Parenthood Available online some states, including WA Nurx.com Prjkt Ruby (also donates to one month of pills to developing country) More (bedside.org, 10/26/17) Patch should be applied on same week day Typical effectiveness: 91% Effectiveness with perfect use: 99% (source: Planned Parenthood) Photo source: James Hellman, MD, via Wikimedia Commons

NuvaRing Typical effectiveness: 91% Insertion of ring into vagina Remains in place for three weeks Combination method: estrogen & progestin Typical effectiveness: 91% Effectiveness with perfect use: 99% Cost: $0-200/month (Planned Parenthood) Physician, Planned Parenthood, online Insertion (YouTube, 0:45-1:20)

Nexplanon An implant One rod inserted under skin, inner arm Can feel implant Progestin-only Effectiveness: 99% Lasts up to three years Cost: $0-1300 (Planned Parenthood) Upon removal, fertility returns to normal within several weeks Sensitive Nexplanon insertion video (TimeofCare, 2:13) Nexplanon insertion (LARC video series animation, 2:15+)

Depo-Provera Progestin-only contraceptive Cost: $0-100 (Planned Parenthood) Typical Effectiveness: 94% Effectiveness with perfect use: 99% Hormone is injected every three months Arm Buttocks Depo-Provera works by preventing ovulation, thickening cervical mucus, altering endometrium

Contraceptive Pills Combination Minipill Two synthetic hormones: estrogen (usually ethinyl estradiol) plus progestin Many types of pills Varies by hormone release Varies by type of progestin Varies by amount of hormone Low estrogen (20 mcg) Higher estrogen (30- 35mcg) Varies by pill # (24, 26, 91, 365) Non-continuous, continuous hormone Minipill Contains only progestin Norethindrone FDA considering drospirenone (May 27, 2019) 28-pill pack (no placebo) Not all minipill users ovulate consistently, so bleeding may be unpredictable Fewer serious side effects Less effective (91-97%) Dawn Stacey, PhD & LMHC & Meredith Shur, MD, verywell.com

Oral Contraceptive Technology Traditional 21-day hormone pill packs 24-day hormone packs Chewable packs Femcon Extended pill cycles Seasonique, Loseasonique, Seasonale, Lybrel Different estrogen Natazia has estradiol valerate

Intrauterine Contraceptives (IUCs) IUC’s are made of flexible plastic, available only through prescription Effectiveness: 99% Cost: $0-1000 (Planned Parenthood) Two types (U.S.) Hormone-based IUC’s Mirena Skyla Liletta Kyleena ParaGard (copper-based IUC)

Hormone Intrauterine Contraceptives: Mirena, Skyla, Kyleena, Liletta Progestin-only: levonorgestrel Last 3-5 years How hormone IUC’s work: Prevent sperm from fertilizing ovum Prevent release of egg Change uterine lining

Hormone-Based Intrauterine Contraceptives: Mirena – 20 mcg of hormone, 5 years Liletta, 19.5 mcg, 4 years Kyleena, 17.5 mcg, 5 years Skyla, 14 mcg, 3 years Complication effects: ovarian cysts, pelvic inflammatory disease shortly after insertion, perforation of uterus, expulsion

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, colorectal cancer Reduced menstrual, endometriosis, migraine pain (pills, implant) Control of excess hair growth, acne Reduced acne Source: Dawn Stacey, Meredith Shur, verywellhealth.com, 2/7/18

Emergency Contraception A variety of pills Plan B available without prescription Generics of Plan B available without prescription Ella available with prescription Copper IUD Requires insertion by healthcare provider No age restrictions Must be taken within 5 days of unprotected vaginal sex Mechanism: delays or prevents ovulation No evidence suggests it prevents implantation of fertilized ovum Source: Emergency Contraception, Princeton University

IUC: 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 Effectiveness: 99%

IUC: 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 10-12 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: 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

Sterilization Male reproductive anatomy: vasectomy Female reproductive anatomy: tubal ligation, or implant (implant no longer available as of 12/31/18) Second most common contraceptive method in U.S. 700,000 tubal ligations annually 500,000 vasectomies annually Resource: Deborah Bartz, MD, MPH, & James A. Greenberg, MD, Sterilization in the United States Cost: $0-1000 for vasectomy, $0-6000 (Planned Parenthood)

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 isolated, then cut and tied, clamped, and/or cauterized; no scalpel technique reduces healing time Another form of contraception must be used for a few months Side effects: bruising, discomfort/pain, sperm leaking from vas may lead to small lump (usually clears up on its own), antibodies to sperm may develop, reducing chances of fertility in a reversal

Sterilization: Vasectomy 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 Animation (BUPA Health via YouTube, 2:36) Nucleus Medical Media (YouTube, 0-1:18, 1:45+) 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 Tubal ligation is different from hysterectomy (removal of uterus, potential additional removal of ovaries and fallopian tubes)

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: $0-6000 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 Animation (YouTube) Side effects: expulsion of coil inserts, risk for ectopic pregnancy, cramping, menstrual changes, nausea/vomiting Thousands of complaints regarding implant complications reported to FDA (NY Times, 2015) Pain, perforated uterus or fallopian tubes, migration of inserts, sensitivity/allergic reactions Bayer halted sales outside U.S. in September 2017, citing commercial reasons Bayer finally halted sales in U.S. on December 31, 2018

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 occurring from vaginal-penile intercourse, 100 “couples” across the course of a year Effectiveness can increase when using more than one FAM, or additional non-FAM contraceptives No sexually transmitted infection prevention

Abstinence & Withdrawal Abstinence a relative term To avoid pregnancy: No vaginal-penile sex No other forms of sex that bring sperm into vaginal canal Withdrawal During vaginal-penile sex, penis is removed from vagina before ejaculation “Coitus interruptus” “Pull-out” method Up to 80% effective (Planned Parenthood)

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

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)