1. Contraception
Winter 2019

2. 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)

3. 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 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)

4. Contraceptive Issues
You Decide

5. 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

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

7. Contraceptives – How They Work with Anatomy & Physiology

8. Hormone Contraceptive Methods

9. 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)

10. 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

11. Estrogen
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

12. Progestin 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

13. 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

14. Hormonal Contraceptives Side Effects
Varying levels of estrogen and progestin can influence effects
Chart (Dawn Stacey, about.com)
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

15. Xulane “The patch” Releases estrogen and progestin
Applied 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
If detaches for less than a day, apply a new patch; if more than a day, apply new patch and begin new cycle

16. Xulane 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
Effectiveness: 99%
Photo source: James Hellman, MD, via Wikimedia Commons

17. Xulane: Side Effects, Contraindications
Breast tenderness (~20%)
Headache
Sensitivity to adhesive
Nausea
Menstrual cramping
Increase in HDL, LDL, triglycerides
Upper respiratory infections
Increased blood clot risk, stroke vs contraceptive pills
Contraindications: smoking over the age of 35 years, cardiovascular conditions, some cancers, diabetes-related issues, pregnancy, liver issues, some medications; overweight/obesity (less effective in women >90kg)
Source: Xulane.com

18. NuvaRing Insertion of ring into vagina
Remains in place for three weeks
Combination method: estrogen & progestin
Effectiveness: 90-99%
Cost: $0-200/month (Planned Parenthood)
Physician, Planned Parenthood, online
Insertion (YouTube, 0:45-1:20)

19. NuvaRing: Side Effects, Contraindications
Vaginal irritation
Nausea
Weight gain
Irregular bleeding/spotting
Rash
Serious, rare: blood clots, gallbladder disease, cancer, liver growths, pancreatic inflammation (triglycerides), cardiovascular incidents
Contraindications: same as Xulane, but also toxic shock syndrome
Obesity/overweight: NuvaRing works better than patch
Gordon, Thakur, & Atlas. What Hormonal Contraception is Most Effective for Obese Women? Journal of Family Practice. Vol 56, No. 6:

20. Nexplanon An implant One rod inserted under skin, inner arm
Can feel implant
Low-dose progestin-only
Effectiveness: 99%
Lasts up to three years
Cost: $ (Planned Parenthood)
Upon removal, fertility returns to normal within several weeks
Sensitive Implanon insertion video (YouTube, 2:08)
Nexplanon insertion (YouTube, 0:42)

21. Nexplanon: Side Effects
Progestin-only, so cardiovascular effects may be less pronounced than combination methods
Irregular bleeding
Headache
Depression
Breast tenderness
Acne
Weight gain
Contraindications: liver issues, blood clots, abnormal bleeding, breast cancer; obesity/overweight – need more research

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

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

24. 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

25. Depo-Provera Reduced sexual appetite Hot flashes Hair loss
May reduce risk for ovarian, endometrial cancers
In high-risk populations, may increase risk of acquiring HIV (Ralph, et. Al., Lancet, vol. 15, no. 2, pp , February 2015)
Possibly thins epithelial cells that keep toxic agents out of body
Other, rare side effects: chest pain, pulmonary embolus, tachycardia, fever, breast lumps, anemia, fainting, vaginal cysts, asthma (rxlist.com)

26. 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
Contraindications: liver issues, cardiovascular conditions, abnormal bleeding, some cancers

27. 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)
Minipill
One synthetic hormone: progestin
Norethindrone
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

28. 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

29. 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

30. 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

31. 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

32. 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)

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

34. Hormone Intrauterine Contraceptives: Mirena, Skyla, Kyleena
Intrauterine device
Progestin-only
Lasts for five years
Mirena:
Prevents sperm from fertilizing ovum
Prevents release of egg
Changes uterine lining

35. Hormone IUC’s: Mirena Insertion: Similar to ParaGard
Effectiveness: 99%+ against pregnancy
Cost: $ (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

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

38. 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

39. 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

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

41. Sterilization

42. 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)

43. 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

44. 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

45. Sterilization: Vasectomy
Cost: $ (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

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

47. 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

48. 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

49. 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)

50. 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

51. 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)
Bayer halted sales outside U.S. in 2017, citing commercial reasons

52. 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

53. 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

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

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

56. 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

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

58. 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

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

60. 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)

61. 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

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

63. 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

64. 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

65. 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

66. 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)

67. 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: $ per condom
New condom for each act

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

69. 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

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

71. 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

72. Contraception: Impact of Heat on Sperm

73. 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 ( )