Contraception Methods Side Effects

Contraception

• Hormonal methods: need a prescription, not effective against STIs, and may have side effects like nausea, breast tenderness, and mood swings.
• Progestin methods: may cause irregular bleeding, and have adverse reactions like blood clots.
• Contraindications: migraine with aura, hypertension, history of DVT, PE, stroke, and smokers over 35.
• Not suitable for breastfeeding mothers.

Combined Oral Contraceptive Pills

• Contain 21 hormone-containing pills followed by 7 placebo pills.
• Extended cycling: 84 active pills, 7 days placebo.
• Can help with PCOS, acne, menstrual cramping, and heavy bleeding.
• Missed dose: take a pill as soon as you remember, then take the next dose at the regular time.
• If you miss more than one, take the next dose, but use other birth control for 7 days.
• More effective in women who weigh over 165 pounds.

Emergency Contraception

• Levonorgestrel (PlanB): available over the counter or by prescription, more effective when taken within 72 hours of unprotected intercourse.
• Works by preventing ovulation, does not affect an established pregnancy.
• Must be used within 72 hours of unprotected sex.
• Ulipristal (Ella): available by prescription only, works as a progestin blocker, and may affect an existing pregnancy.
• May be used within 120 hours of unprotected intercourse.

Intrauterine Devices (IUDs)

• Types: copper (Paragard) and progestin-releasing (Mirena and Skyla).
• T-shaped device inserted into the uterus, works by thinning the lining of the uterus and creating an environment not good for sperm.
• Hormone-releasing IUDs also prevent ovulation.
• Does not interrupt a pregnancy or cause abortion.
• Advantages: no chance of user error, completely reversible, and long-acting.
• Disadvantages: initially expensive, may not be accessible to some women, and may cause heavier bleeding and cramping.

Barrier Methods of Birth Control

• Male Condoms:
• Consist of a sheath that goes over the penis, provide a barrier that prevents semen from entering the female reproductive tract.
• Advantages: widely available, inexpensive, protect against STIs, allow male partner to be active in family planning.
• Disadvantages: adherence is poor, breakage or slippage may occur, latex allergy is a contraindication, and can degrade over time.
• Female Condom:
• Contains two semi-rigid rings attached to the opening of a nitrile tube.
• Placement is similar to a tampon, new female condom should be used with each episode of rectal or vaginal sex.
• Expensive and more cumbersome than a male condom.
• Diaphragm:
• Flexible saucer that is placed into the vagina to cover the cervix.
• Does not protect against STIs, has a 12% failure rate within a year.
• Fit should be checked if the woman gives birth, has a miscarriage or abortion, or gains or loses more than 10 pounds.

Fertility and Infertility

• Infertility: lack of pregnancy after 12 months of well-timed intercourse (6 months if the woman is over 35 years old).
• May involve recurrent spontaneous abortion (miscarriage).
• Infertility may be related to male factors (35%), female factors (35%), and combined male and female factors (20%).
• In about 10% of infertility cases, the cause is unknown.
• Overweight or underweight women may be counseled to lose or gain weight to induce ovulation.

Fertility Treatment

• Clomiphene:
• Selective estrogen receptor modulator, common first-line medication to induce ovulation.
• Started 5 days after the start of menses, the risk of miscarriage or ectopic pregnancy is the same as with spontaneous pregnancies.
• The risk of multiple gestation is increased 7% with clomiphene citrate compared to spontaneous pregnancies.
• Human Menopausal Gonadotropin (Pergonal):
• Self-administered IM injection given daily until ultrasound reveals a mature ovarian follicle.
• Directly stimulates ovaries, recommend intercourse every other day for 1 week starting day 5 of beginning medication.
• Patient required to come in for multiple office visits per cycle for labs and ultrasound.
• Risk of ovarian hyperstimulation, serious cases require hospitalization.
• The risk of multiple gestation is 10-20% (majority are twin gestation).

Artificial Reproductive Technology (ART)

• Multiple modalities exist, and may sometimes be combined to increase odds:
• Intrauterine Insemination (IUI):
• Sperm is washed and then introduced into the upper uterine cavity.
• In Vitro Fertilization (IVF):
• Used to treat infertility due to tubal factors, severe male factors, uterine, or ovarian factors.
• Ovaries are stimulated and eggs retrieved by ultrasound-guided follicle aspiration and then mixed with cleaned sperm.
• Successful fertilization can be identified after 17 hours and transplanted into the uterus or frozen.
• Gamete Intrafallopian Transfer (GIFT):
• Sperm and eggs are combined and then placed in the fallopian tube for fertilization via laparoscopy.
• Requires general anesthesia and surgical intervention.
• Intracytoplasmic Sperm Injection (ICSI):
• Sperm is retrieved from the epididymis using a needle through the skin, and a single sperm cell is isolated and injected into an egg.
• Donor Sperm:
• Sperm is obtained from a donor, washed and used for fertilization either with IUI or IVF procedures.
• Donor Oocytes:
• Eggs are obtained from donors and combined with sperm (male partner's or donors) in IVF.
• Surrogacy (Gestational Carrier):
• Can use couple's or donor egg/sperm.

Intrauterine Contraception (IUC)

• IUCs have a small risk of perforating the uterus during insertion.
• The incidence of pelvic inflammatory disease is the same for women with IUCs as for women without them.

Barrier Methods of Birth Control

• Male Condoms
  • Consist of a sheath that goes over the penis
  • Provide a barrier that prevents semen from entering the female reproductive tract
  • Most are latex-based; non-latex are made from animal intestine
  • Advantages: widely available, inexpensive, protect against STIs, allow male partner to be active in family planning
  • Disadvantages: poor adherence, breakage or slippage, latex allergy, degrade over time
• Female Condom
  • Contains two semi-rigid rings attached to a nitrile tube
  • Placement is similar to a tampon
  • A new female condom should be used with each episode of rectal or vaginal sex
  • Expensive and more cumbersome than a male condom
• Diaphragm
  • A flexible saucer that is placed into the vagina to cover the cervix
  • Does not protect against STIs
  • 12% failure rate within a year
  • Fit should be checked after childbirth, miscarriage, or abortion, or if weight changes by more than 10 pounds
  • Should be replaced every 2 years
• Contraceptive Sponge
  • A spermicide-infused, foam disk that fits over the cervix
  • Available over the counter
  • 12% failure rate in women who have never given birth, 24% failure rate in women who have given birth
  • Should be placed up to 24 hours before sexual intercourse and stay in no more than 30 hours

Contraception

• Access to Contraception
  • Increases educational and economic opportunities for men and women
  • Reduces maternal mortality/morbidity
  • Decreases infant mortality/morbidity
  • Reduces stress on families
  • Prevents unsafe abortions
• Contraception Considerations
  • The best method is the one that is accessible, affordable, and can be used consistently
  • Methods that don't invite user error have lower failure rates
  • Only condoms prevent infection while preventing pregnancy

Hormonal Methods

• How they Work
  • Suppress ovulation, thicken cervical mucus, and thin the uterine lining
• Effectiveness
  • In a perfect world, failure rate is 0.3%
  • In reality, failure rate is 3-8% depending on the method
• Advantages
  • No effect on future fertility, relieves PMS, lighter periods, no impact on spontaneity, can be used to treat PCOS, reduces acne
• Disadvantages
  • Need a prescription, not effective against STIs, side effects, adverse reactions, contraindications

Surgical Methods

• Tubal Ligation
  • Most common method around the world and 2nd most common in the US
  • Can be performed outpatient or during a C-section
  • Surgical procedure with associated risks
  • Failure rate is 0.5%
• Vasectomy
  • Safer and cheaper than bilateral tubal ligation, but fewer men have the procedure
  • Cutting the vas deferens prevents sperm from exiting the male body
  • Performed in an office under local anesthesia
  • Permanent procedure, but reversal is possible

Contraceptive Patch

• How it Works
  • A patch containing estrogen and progestin applied weekly for 3 weeks
  • Followed by a patch-free week, which causes a withdrawal bleed
• Failure Rate
  • 9% with normal BMI, higher with obesity
• Not for
  • Breastfeeding mothers

Contraceptive Injection (Depo-Provera)

• How it Works
  • A progestin-only injection given every 13 weeks until pregnancy is desired
• Failure Rate
  • 6%
• Concerns
  • Weight gain, used with breastfeeding mothers may diminish milk production

Contraceptive Implant (LARC)

• How it Works
  • A 4-cm rod of non-estrogen etonogestrel is inserted under the skin of the inner upper arm
  • Approved for use for 3 years
• Failure Rate
  • Less than 0.05%
• Concerns
  • Unscheduled bleeding, removal can be difficult, leaves scars

Emergency Contraception

• Options
  • Medication or a copper intrauterine contraception (IUC)
• Progestin-only Pills (POPs)
  • Contain only progestin
  • Safe for breastfeeding mothers
  • Failure rate is 9%