Contraception Potpourri

Hormonal Contraception How It Works, Various Forms

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

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 mucus – Thicker mucus hampers sperm movementmucus Progestin also changes the endometrial lining – 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

Hormonal Contraception: Contraindications Women with history of venous clots, coronary artery disease, stroke, diabetes with blood vessel damage, high blood pressure, breast cancer, abnormal bleeding, liver problems Smoking Obesity? (pills = most controversy; IUD, implant recommended, per Edelman et. Al., uptodate.com) Edelman et. Al., uptodate.com

Ortho Evra “ The patch ” Beige plastic patch applied to the skin – Once a week for three weeks – Stomach, upper arm, upper torso – First day of menses or first Sunday after period starts Releases estrogen and progestin

Ortho Evra Cost: Included with insurance; average wholesale price is ~$0-80/month (Planned Parenthood) Patch should be applied on same week day Effectiveness: 99%

Ortho Evra: Side Effects Breast tenderness (~20%) Headache Sensitivity to adhesive Nausea Menstrual cramping Increase in HDL, LDL, triglycerides Upper respiratory infections Increased blood clot risk vs contraceptive pills Source: OrthoEvra.comOrthoEvra.com

NuvaRing Insertion of ring into vagina Remains in place for three weeks Combination method: estrogen and progestin released Cost: $0-80/month (Planned Parenthood) Insertion (YouTube, 0:45-1:20) Insertion

NuvaRing: Side Effects Vaginal irritation Nausea Weight gain Irregular bleeding/spotting Rash Serious, rare: blood clots, gallbladder disease, cancer, liver growths, pancreatic inflammation (triglycerides), cardiovascular incidents

Nexplanon/Implanon Implanon approved by FDA in 2006 An implant – One rod (Norplant-six) – Inserted under skin, inner arm – Can feel implant Low-dose progestin release Good for three years

Nexplanon/Implanon 1.5 inches in length Effectiveness: 99% Cost: Included with insurance; $0-800 (Source: Planned Parenthood) Upon removal, fertility returns to normal within several weeks Sensitive insertion video (YouTube, 2:08)video

Nexplanon/Implanon: Side Effects Irregular bleeding Headache Depression Breast tenderness Acne Weight gain

Depo-Provera Approved by the FDA in 1992 Progestin-only contraceptive for females Hormone is injected every three months – Arm – Buttocks Depo-Provera works by preventing ovulation, thickening cervical mucus, altering endometrium

Depo-Provera Effectiveness – Protection immediate if first shot occurs during first five days of period; otherwise, use other contraceptive method for two weeks – Greater than 99% effectiveness (MayoClinic.com=97%) Cost: quarterly doctor visit + $0-100 quarterly injection (Planned Parenthood)

Depo-Provera: Side Effects Headaches Dizziness Nausea Breast tenderness Fatigue Weight gain – 5 pounds or more after one year Appetite change

Depo-Provera: Side Effects Abdominal pain Acne Mood changes Bloating Menstrual irregularities (lighter, heavier, cessation) Bone density loss – Unclear whether condition will improve when injections stop Calcium supplements Weight bearing exercise advocated – FDA ’ s “ black box ” warning in 2004 Avoid long-term use (> 2 years) – Association of Reproductive Health Professionals report concern might be less than originally thought Association of Reproductive Health Professionals

Depo-Provera Side Effects Reduced sexual appetite Hot flashes Hair loss May reduce risk for ovarian, endometrial cancers Other, rare side effects: chest pain, pulmonary embolus, tachycardia, fever, breast lumps, anemia, fainting, vaginal cysts, asthma (rxlist.com)

Depo-Provera: Side Effects Side effects may continue until Depo-Provera is out of system, up to six months Some women experience no reversibility problems; others take 6-18 months to return to normal

Depo-subQ Provera 104 Subcutaneous, rather than deep muscle, injection – Thigh or abdomen 31% lower dose of progestin (Dawn Stacey, about.com) (Dawn Stacey, about.com) Similar side effects Since newer product, less information known

Contraceptive Pills “Combination” = estrogen & progestin Minipill = progestin only Beyaz, Femcon Fe

Contraceptive Pills Seasonique & Natazia

Sterilization

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 Similar to tubal ligation, 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: $ (plannedparenthood.org) Side effects – Bruising – Sensitivity/pain for up to a few weeks past the procedure – 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

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

Sterilization: Vasectomy Animation (BUPA Health via YouTube, 2:36) Animation Open-ended (no scalpel) vasectomy (medicalvideos.us) Video (vasectomymedical.com) Video

Sterilization: Tubal Ligation Surgical technique 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 tied and cut – Tubes can be cauterized Tubes can be cauterized – Tubes can be clipped, clamped Tubes can be clipped, clamped – These incision methods often performed after childbirth/abortion – Animation (SMART imagebase) Animation

Sterilization: Tubal Ligation Cost: $ 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) Before/after photos

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 Demo (Essure) Demo Late November: reports of problems coming to a head: headaches, pelvic pain, chronic fatigue, coils moving to other parts of body and hurting tissue, others “Pre-market approval” = exempt from lawsuits

Long-Term Contraception & Sterilization: Project Prevention Societal aid or eugenics? – FOX News program (1:30 minutes)program – ABC News program (2:19 minutes)program

Fertility Awareness Methods

Temperature Method Females track temperature every morning Look for slight drop in temperature occurring immediately before ovulation At ovulation, temperature increases Temperature changes are small Look for trends, expect daily fluctuations Image source: Public domain, Wikimedia Commons

Temperature Method Use basal thermometer – Smaller scale (1/10 degree) Chart temperature for at least three months before relying on method Safe sex time begins 72 hours after temperature has risen, remains until temperature begins to drop Source: Dr. Sacha Elliott, ND

Temperature Method Day 10: 98.5Day 17: 98.8 Day 11: 98.4Day 18: 99.0 Day 12: 98.4Day 19: 98.7 Day 13: 98.1Day 20: 98.7 Day 14: 97.9Day 21: 98.8 Day 15: 98.0Day 22: 98.6 Day 16: 97.5Day 23: 98.5

Cervical Mucus Method Tracking the variation in mucus consistency throughout cycle Cervical mucus begins a few days after menstruation As mucus production increases, it ’ s yellow or white in color & cloudy, sticky Will become wet, clear Clear, slippery mucus = most fertile Mucus production decreases, cloudy & sticky

Cervical Mucus Method Tracking Your Cervical Mucus, Babycenter.com Tracking Your Cervical Mucus “ Safe days ” = begin after slippery mucus decreases, continue into cloudy & tacky, and especially dry days Short cycles = mucus may be hidden in menstrual flow

Calendar Method Predicting “ safe ” and “ unsafe ” days based on length of monthly cycles Can use traditional calendar, software, phone app, web tools

Calendar Method Count length of menstrual cycle – Day #1 = first day of menses – Last day = day before menses returns – Eight cycles are recommended before relying on this method (Planned Parenthood) – First fertile day = shortest cycle minus 18 – Last fertile day = longest cycle minus 11

Calendar Method Cycle 1: 24Cycle 2: 27 Cycle 3: 25Cycle 4: 28 Cycle 5: 25Cycle 6: 27 Cycle 7: 29Cycle 8: 25 Shortest day: 24 Longest day: 29 Unsafe days: #6-18

Calendar Method Online calendar method tool - virtualmedicalcentre.com virtualmedicalcentre.com Irregular period cycles = reduced effectiveness Calendar method = requires another method for most to experience adequate effectiveness

Contraception in the Future: Nestorone Estrogen and progestin Gel Spray Acrux Announcement, February 2009 Acrux Announcement Figure 2: Estrogen content in Nestorone, OrthoEvra, NuvaRing, combination pills 2012: Combination of nestorone and testosterone reduced sperm count in UCLA study study

Contraception: The Future Male hormonal contraceptive: monthly testosterone injection 5/ 2009: China clinical trials – 1 in 100 fathered a child – Reversible six months after stopping injections – 1/3 of 1000 participants did not complete; no reason provided – Few side effects reported (acne, weight gain), but more research needed – Contraceptive methods may work better in Asian men vs European men – Photo from BBC

Contraception: The Future RISUG – Reversible Inhibition of Sperm Under Guidance – Contraceptive method for men – Clinical trials in India – Injection into vas deferens of male (video, wired.com, :34)vas deferens video – RISUG disrupts membranes of sperm so they cannot fertilize – One injection to last 10 years – Reversibility not well tested, though reports on primates appear positive (requires another injection) – Marketing challenges

Contraception: The Future Male contraceptive pill research at UW (KOMO report, 2009, 2:10, YouTube)contraceptive pill research Non-hormonal manipulation of sperm production has been successful in mice (2012) Vitamin A blocking can reduce fertility (but Vitamin A needed for other bodily functions)

Contraception: The Past Male Contraceptive: Heat – Prolonged heat exposure can impair sperm production in testes – Ancient method – Effectiveness? 116 degree bath 45 minutes Every day Three weeks

Contraception: Impact of Heat on Sperm

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 ( )

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 ( )

Intrauterine Contraceptives (IUC ’ s) IUC ’ s are made of flexible plastic, available only through prescription Three types – ParaGard (copper) – Mirena (hormone) – Skyla (hormone)

IUC ’ s: ParaGard ParaGard contains copper Copper prevents sperm from fertilizing an ovum Copper also makes implantation of fertilized ovum difficult 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 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: $ (Planned Parenthood)

IUC ’ s: Mirena Progestin-only intrauterine contraceptive Lasts for five years Mirena: – Prevents sperm from fertilizing ovum – Prevents release of egg – Changes uterine lining

IUC ’ s: Mirena Insertion: Similar to ParaGard Effectiveness: 99%+ against pregnancy Cost: $0-400 (Consumer Reports) 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

IUC: Skyla FDA approved in 2013 Hormone Smaller than Mirena Lasts three years instead of five Marketed to women who have not had kids – Mirena marketed to women with child (research done only on this group) – IUC’s appropriate for all women

IUC ’ s Internal Birth Control- IUD ’ s (via Youtube) Internal Birth Control- IUD ’ s Paragard insertion (via YouTube, 0-0:53) Paragard insertion Mirena insertion (via YouTube, for healthcare providers) Mirena insertion Insertion of IUC (Medialvideos.us)IUC