Contraception

    Absolute Contraindications to Contraception

     

    • Current pregnancy
    • Undiagnosed vaginal bleeding
    • Active cardiovascular/thromboembolic diseases
      • coronary and carotid disease
      • symptomatic mitral valve prolapse
      • CVA
      • Active DVT
    • moderate-severe HTN
    • proliferative retinopathy
    • Hx of Estrogen-Related Tumors:
      • Liver, breast, uterus
    • Impaired liver function (obstructive jaundice in pregnancy)
    • Congenital hyperlipidemia
    • Age > 35 and smoking
    • Wilson’s disease

    - Away to remember: 

    Think 3 things: pregnancy, undiagnosed vaginal bleeding, cancer

     Then think of 5 cardinal risk factors of heart disease (smoking, hypercholesterolemia, hypertension, family hx (thromboembolism), diabetes (proliferative retinopathy).

    Contraception Options and Stats

     

      Unintended pregnancies within first year of use (%)26        
    Method Typical use* Perfect use † Women continuing use at one year (%)26 Frequency of use Protection against STDs8 Use while breastfeeding8 Cost‡

    None

    85

    85

    Spermicide

    29

    15

    42

    Each time

    No §

    Yes

    $ 0.35 to 12

    Withdrawal

    27

    4

    43

    Each time

    No

    Yes

    None

    Periodic abstinence

     

    Calendar method

    25

    9

    ∼ 50

    Each time

    No

    Yes

    None

     

    Ovulation method

    25

    3

    ∼ 50

    Each time

    No

    Yes

    None

     

    Symptothermal method‖

    25

    2

    ∼ 50

    Each time

    No

    Yes

    None

     

    Postovulation method

    25

    1

    ∼ 50

    Each time

    No

    Yes

    None

    Cervical cap: parous women∥

    32

    26

    46

    Each time

    No

    Yes

    30 to 40

    Cervical cap: nulliparous women∥

    16

    9

    57

    Each time

    No

    Yes

    30 to 40

    Diaphragm∥

    16

    6

    57

    Each time

    Yes#

    Yes

    30 to 40

    Female condom

    21

    5

    49

    Each time

    Yes

    Yes

    2 to 3 each

    Male condom

    15

    2

    53

    Each time

    Yes

    Yes

    0.50 to 2 each

    OCPs

    8

    0.3

    68

    Taken daily

    No

    ** † †

    20 to 50 per cycle

    Contraceptive patch

    Unknown

    0.3

    68

    Applied weekly

    No

    **

    36 per month

    Vaginal ring

    Unknown

    0.3

    68

    Inserted every 4 weeks

    No

    **

    43 per month

    Progestin-only OCPs

    3

    0.3

    56

    Given every 12 weeks

    No

    Yes

    30 to 35 every 3 months‡ ‡

    Copper-containing IUD

    0.8

    0.6

    78

    Inserted every 10 years

    No

    Yes

    250 to 300 every 10 years§ §

    Levonorgestrel intrauterine system

    0.1

    0.1

    81

    Inserted every 5 years

    No

    Yes

    300 to 400 every 5 years§ §

    Female sterilization

    0.5

    0.5

    100

    Done once

    No

    Yes

    1,200 to 2,500 ∥ ∥

    Male sterilization

    0.15

    0.10

    100

    Done once

    No

    Yes

    250 to 1,000

     

     

    "

    "Calendar Method"

    Important Principles:
    • Cycle starts on the FIRST day of their menstrual period
    • Ovulation happens 10-14 day of cycle.
    • Egg survives maximum 12-24 hours before breaking up.
    • Sperm survive up to 4 days in the uterus post-ejaculation.
    • Theory behind method (lets say your ovulation happens on day 14)
      • Can "in theory" have sex from day 1-10 (after this sperm will survive long enough to fertilize the egg on day 14).  (Keep in mind that this includes the period).
      • Then egg released for 2 days max
      • Then can resume having sex after day 16 (after egg dies).
    • These numbers need to be adjusted based on the woman's cycle.  You calculate the numbers based on principles:
      • After ovulation, woman CONSISTENTLY has 14 days before start of next cycle (bleeding).  (Luteal phase length)
      • Therefore, adjust time of ovulation based on cycle length.  (Follicular phase length). 
      • Many methods exist to calculate these dates and determine "safe dates" to have sex.
    Drawbacks:
    • Luteal phase (after egg released) CONSISTENTLY lasts 14 days.  However, can be different.
    • Generally cannot use this method if cycle is <26d
     
    There are many methods of calculating fertile and infertile periods, here is an example of one:
                To predict the first fertile day in your current cycle
      • Find the shortest cycle in your record.
      • Subtract 18 from the total number of days.
      • Count that number of days from day one of your current cycle, and mark that day with an X. Include day one when you count.
      • The day marked X is your first fertile day.

    To predict the last fertile day in your current cycle

      • Find the longest cycle in your record.
      • Subtract 11 days from the total number of days.
      • Count that number of days from day one of your current cycle, and mark that day with an X. Include day one when you count.
      • The day marked X is the last fertile day.
    Example of calendar:
     

    Patch

    Ortho Evra or Evra
    • Only one that's approved by FDA
    • Same efficacy as pill with perfect use.
    • IN theory less side effects because no first-pass metabolism by liver.
    • Apply weekly, "change patch day", and after 3 patches, leave it off for 7 days for period.
    • designed to release: 20 µg/day of ethinyl estradiol and 150 µg/day of norelgestromin
    • S/E:
      • Reasons for stopping: nausea and/or vomiting (2.4%), application site reaction (1.9%), breast discomfort, engorgement or pain (1.9%), headache (1.1%), and emotional lability (1.0%)
      • Adverse events: breast discomfort, engorgement or pain (22%), headache (21%), application site reaction (17%), nausea (17%), upper respiratory tract infection (10%), menstrual cramps (10%), and abdominal pain (9%)
     

    Intrauterine System

    Mirena
    • 20mcg of lenovogestrel per day
    • lasts 5 years.
    • costs $400
    • As effective as copper IUD - comparable to surgical sterilization
    • Less bleeding and dysmenorrhea (unlike copper).
      • May have irregular bleeding x6mo when starting followed by light menses.
      • 20% amenorrhea at one year of use.
    • local progesterone atrophies the endometrial lining, and Estradiol levels maintained - no osteopenia. 
    • Maybe slight increase in headaches and acne
    • When stops, may take up to 12mo for period to return.
    Copper
    • Effectiveness similar to surgical sterilization
    • costs $200
    • Side effects:
      • Heavy bleeding.
      • High risk of ectopic if pregnancy does occur.
      • lower risk of PID
      • Risk of expulsion
     

    Side Effects

    Bloating
    Weight Gain
    Mood swings
    Decreased libido 
    • Controversial: in some women increases libido, in some women decreases it (studies aren't consistent).  However it appears that there is a CHANGE in libido using OCP.
    • apparently monophasic are the worst at this
    • The non-oral forms (such as patch), do not have an effect on libido.
    (controversial, apparently monophasic are the worst
     
     

    Extended Cycle

    Seasonale - 91 days; ethinyl estradiol (30 mcg) & levonorgestrel (150 mcg)
    Alesse - smallest doses of ethinyl estradiol 0.02 and levonorgestrel 0.1
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