1. Contraception
Winter 2019

2. 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

3. 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

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

5. Contraceptives – How They Work with Anatomy & Physiology

6. Hormone Contraceptive Methods

7. 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)

8. 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

9. 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

10. 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)

11. 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)

13. 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)

14. 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

15. 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)

16. Nexplanon An implant One rod inserted under skin, inner arm
Can feel implant
Progestin-only
Effectiveness: 99%
Lasts up to three years
Cost: $ (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+)

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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%

27. 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 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

28. 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

29. 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: $ for vasectomy, $ (Planned Parenthood)

30. 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

31. 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

32. 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 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)

33. 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)

34. 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

35. 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)

36. 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

37. 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

38. 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

39. 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

40. 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)

41. 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

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

43. 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

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

45. 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)

46. 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

47. 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

48. Contraception: Impact of Heat on Sperm

49. 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 ( )