1. Contraception: A problem-based approach Alice Chuang, MD, FACOG Department of Obstetrics & Gynecology Division of Women’s Primary Health Care

2. Case 1: A 23 year old presents to your office for her annual exam. She tells you that she has concerns about taking the Pill because a friend of hers just had a blood clot in her leg while on the Pill. She would like another form of birth control. She is married; she has completed her childbearing. She was originally placed on the pill because she had heavy menstrual cycles. You suggest: a) A different brand of oral contraceptive b) The Mirena IUD c) The copper IUD d) A tubal ligation

3. Objectives: Be able to describe and list the many available forms of contraception Be able to discuss their advantages and disadvantages Be able to select the right method of birth control to improve patient compliance and satisfaction

4. Contraception: introduction 48% of pregnancies in the US are unintended In 2000, 25% of all pregnancies ended with an induced abortion. We are doing a bad job of preventing unintended pregnancy!

5. Contraception: introduction With unprotected intercourse: After 1 year, 85% of couples will get pregnant During menses, 1% chance of pregnancy per act of unprotected coitus Midcycle, 17-30% chance of pregnancy per act of unprotected coitus

6. What is the perfect form of contraception? Reversible v. irreversible Hormonal v. nonhormonal Low maintenance v. high maintenance It depends on the individual patient!

7. Case 2: A 29 year old presents to your office for her annual exam with no complaints. When asked if she is sexually active, she replies that she is. When asked if she needs contraception, she states no. You: a) Stress that contraception is important in order to prevent pregnancy. b) Ask her if she is planning to get pregnant because if not, then she needs contraception. c) Remind her that the natural family planning is not very effective at preventing pregnancy.

8. Case 3: A 38 year old presents to your office for her annual exam. She would like some contraceptive recommendations. She has completed her childbearing and wants to have her tubes tied. You suggest the IUD, but she feels strange “having something inside her.” You suggest:

9. Tubal ligation Failure rates 0.8% postpartum salpingectomy 3.7% Hulka spring clip Mechanism: occlusion/interruption Pros: permanent, highly effective Cons: requires surgery, risk of ectopic pregnancy with failure, not reversible, does not prevent STI’s, risk of regret US Collaborative Review of Sterilization. The risk of pregnancy after tubal sterilization. Am J Obstet Gynecol 1996:174:1161-70

10. Essure (transcervical sterilizaton) Failure rates: 0 (n=453) Mechanism: polyester fibers (PET) placed hysteroscopically induce local tissue growth and tubal blockage

11. Essure (transcervical sterilization) Pros: highly effective, office procedure with rapid recovery, average procedure time = 13 minutes Cons: May require more than one procedure, tubal spasm, possible expulsion, need verification of occlusion with hysterosalpinogram 3 months afterwards, very difficult to reverse

12. Vasectomy Failure rate: 0.15% in first year Mechanism: interrupting vas deferens Pros: simpler, safer than female sterilization Cons: use backup method until sperm count = 0, possible regret, requires surgery, does not prevent STI’s

13. Case 4: A healthy 25 year old presents to your office for her annual exam. She is getting married in 3 months and is not ready to start a family, but would like to in a few years. She has a cousin who recently got married and is using the patch, but she does not “trust” these newer methods of birth control. You offer her…

14. The Pill (ethinyl estradiol/various progestins) Efficacy: 0.3-8% Mechanism: inhibit ovulation, thickens cervical mucus, decreases tubal mobility, thins endometrium

15. The Pill (ethinyl estradiol/various progestins) Pros: Decreased anemia, dysmenorrhea, mittelschmerz, benign breast disease, ovarian cancer, endometrial cancer, decreased corpus luteum cysts, decreased death from colorectal cancer Cons: No protection against STI’s, daily oral dosing,

16. The Pill (ethinyl estradiol/various progestins) Absolute contraindications: Pregnancy Previous or active thromboembolic disease Undiagnosed genital bleeding Smoking and age >35 Estrogen dependent neoplasm Hepatoma Relative contraindiations: Hypertention Diabetes Gallbladder disease Obesity Migraines

17. Case 5: A healthy 25 year old presents to your office for her annual exam. She is getting married in 3 months and is not ready to start a family, but would like to in a few years. She has used condoms in the past but really would like something a little lower maintenance. She has thought about the pill, but is concerned she would forget to take it daily. You offer her…

18. Nuvaring (ethinyl estradiol/etonogestrel) Failure rate: 0.3-0.65% Mechanism: same as OCP’s Pros: only requires insertion/removal, lowest estrogen/progestin dose of any combined hormonal method, comfortable for both partners during intercourse Cons: 25% of cycles accompanied by additional spotting, possible expulsion, does not prevent STI’s

19. Ortho Evra (ethinyl estradiol/norelgestromin) Failure rate: 0.3-8.0% Mechanism: same as OCP’s Pros: requires weekly maintenance, proven better compliance Cons: application site problems, increased nausea and breast tenderness compared to oral contraceptives, does not prevent STI’s, lower efficacy in women > 90kg

20. Case 6: A 25 year old presents to your office for her annual exam. She is married and does not plan to have any more children for at least the next 5 years. She has been on the pill before but would like something low maintenance. She is not interested in any of those “new-fangled” methods like the Patch and that “ring.” You suggest:

21. Mirena IUD (levonorgestrel) Failure rate: 0.1% Mechanism: Thickens cervical mucus, alters tubal motility, thins endometrium, inhibits ovulation (5-15% of cycles) Pros: Decreased menorrhagia, dysmenorrhea; low maintenance, extremely effective Cons: Initial increase in spotting, bleeding; possible amenorrhea (20% after 1 year), possible expulsion, possible perforation with placement and migration afterwards

22. Paraguard T380 (copper IUD ) Failure rate: 0.6% Mechanism: spermicidal effect of copper ions Pros: low maintenance, cost effective, lasts for 10 years, Cons: increased menstrual bleeding and dysmenorrhea, possible perforation at placement or migration later

23. Case 7: A 24 year old presents to your office for her annual exam. Her fiance is stationed overseas. She would like a method that she can use only when he is in town. She does not want to be on the Pill. You suggest:

24. Diaphragm Failure rate: 6-16% Mechanism: Mechanical barrier, spermicide Pros: non-hormonal, Cons: high- maintenance, requires placement prior to act of intercourse and high level of patient skill

25. Condom Failure rate: 2-15% Mechanism: barrier Advantages: Protects against STI’s, no hormonal side effects Disadvantages: Successful use based on education/experience; 3- 5% risk of breakage/slippage

26. Case 8: A 23 year old presents to your office for her annual exam. She will be getting married next month, and her religion precludes her from using any form of conventional birth control. She is not ready to have children. She needs some advice. You offer her:

27. Natural Family Planning Failure rate: 1-25% Mechanism: Timing of intercourse Pros: inexpensive Cons: Difficult to use for the average patient, relatively high failure rate,

28. Case 9: A 23 year old calls your office because she had intercourse last night, and the condom broke. You offer her:

29. Emergency Contraception Options Plan B: Progesterone only Yuzpe Method/Preven: Estrogen + progesterone Copper IUD

30. Emergency Contraception COC’sPlan BCopper IUD Timing ASAP, but can be used up to 3-4 days ASAP but can be used up to 5 days Up to 8 days Effectiveness (pregnancies/ 100 women) 0.4% (<12 hrs) Average 2-3.2% 0.5% (< 12 hrs) Average: 1.1% 0.1% Advantages Wide range of possible pills Fewer side effects, both doses can be taken at once Effective, provides contraception afterwards Disadvantages Gastrointestinal side effects, spotting Less available, spotting, Expensive, insertion required, may have spotting Hatcher RA, Zieman M et al. Emergency Contraception. In A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundtiona, 2005

31. Emergency Contraception: Mechanism of Action If taken before ovulation: Disrupts follicular development Blocks LH surge, thus inhibiting ovulation Thickening cervical mucus Inhibits tubal motility If taken after ovulation: Has little effect Emergency Contraception does not work by disrupting an implanted pregnancy!

32. Case 1: A 23 year old presents to your office for her annual exam. She tells you that she has concerns about taking the Pill because a friend of hers just had a blood clot in her leg while on the Pill. She would like another form of birth control that does not have hormones. She is married; she has completed her childbearing. She was originally placed on the pill because she had heavy menstrual cycles. You suggest: a) A different brand of oral contraceptive b) The Mirena IUD c) The copper IUD d) A tubal ligation

33. Poor choices Irreversible: Tubal ligation Essure Vasectomy Hormonal: OCP’s Ortho Evra Nuvaring High maintenance Diaphragm Cervical cap Natural family planning

34. The Answer: Mirena IUD! Highly effective, low maintenance, decreased menorrhagia and dysmenorrhea, only localized hormonal effect, and reversible