Contraception

David Blair Toub, M.D.

Dept. of Obstetrics and Gynecology
Pennsylvania Hospital
Methods
Oral Contraceptive Pills (OCPs)
Depo-Provera, Norplant
Intrauterine Device (IUD)
Male / Female Condom
Diaphragm
Emergency Contraception (EC)
Efficacy (modified from trussell, et. al 1990)
Failure Rate (Percent) During First Year of Use
6
6

4
3
3
2
2
0.8
1 0.5
0.3 0.2
0.1 0.04
0
Spermicides Comb. Prog. OCP's Diaphragm Condom Depo- Cu-T380A Norplant TL
OCP's Provera
Hormonal Contraception:
Combination OCPs
Contain Synthetic Estrogen/Progestin
Modern E2 Dosage 50 Mcg
Despite Diversity, Side Effects and
Efficacies Similar
Requires Patient Compliance
May Be Monophasic or Triphasic
Combination OCPs:
Mechanism of Action
Suppresses LH / FSH Release
(E2 FSH, P LH)
Progestin Thickens Cervical Mucus and
Alters Endometrium
Major Effect Is Anovulation and
Impairment of Sperm Transport and
Ocyte Implantation
Combination OCPs:
Additional Benefits
Menstrual Regulation
Decreased Risk of Anemia
Ovarian, Endometrial CA: Risk
Lower PID Risk
Prevention of Benign Breast Disease
Combination OCPs:
Side Effects
Breakthrough Bleeding ( 25%)
Amenorrhea
Breast Tenderness, Nausea
H/A (+/)
?HTN
?Weight Gain
Combination OCPs:
Risks
Thromboembolism ( 35 yo, Smoker)
MI (Smokers Only):
< 15 cig/day: 3X Risk
> 15 cig/day : 21X Risk
Liver Adenomas (Very Rare)
Depo-Provera:
Inhibits Ovulation
150 mg q3months (14 day grace period)
Delayed Ovulation After Discontinuation
Main Side-Effects:
Amenorrhea
AUB
Weight Gain
Hair Loss
Norplant:
Implantable for 5 Years
Similar Side Effects as Depo-Provera
Avg. Yearly Failure Rate: 0.8/100
(Increases : > 2/100 after 5 years)
Occasionally Difficult to Remove
Barrier Methods:
Diaphragm: High Failure Rates
Must Remain in ~6 Hrs post-coitus
Best if Combined with Spermicide
UTI Potential
Condom: STD Protection, Inconsistent Use by
Men
Female Condom: Cumbersome, Learning Curve
Today Sponge: As seen on Seinfeld
IUD: Overview
ParaGard (CuT380A), Progestasert
Very Effective (~ TL), Reversable
Risks OVERBLOWN
Monogamy Essential, However
Does Not Protect Against STDs
Can Remain for 10 Years
IUD:
Mechanisms of Action
NOT ABORTIFACIENT!!!!!!!!
Prevents Conception:

Sperm Transport Inhibited

Sperm Survival / Capacitation
Diminished
Prevents Implantation: hCG Levels = 0
IUD:
Work-up
History: STDs, Sexual History, Ectopic
PEx: Size / Configuration of Uterus
Cervical Cultures, Pap
Counseling
IUD:
Contraindications
Lack of Monogomy, High Risk for STDs
Abnormal Uterine Bleeding
Current Pelvic Infection (GC, Chl)
Actinomyces on Pap
???Nulliparity
Pregnancy
Wilsons Dz, Cu Allergy (both rare)
IUD:
Complications
PID: Usually 20 Insertional Contamination
Unproven Role for Prophylactic ABx
Hypermenorrhea
Expulsion
Perforation (< 0.1%)
Failure: IUD Should be Removed
??Ectopic
Emergency Contraception
IUD, OCPs
Specific OCP Regimens Given 72 Hours
After Unprotected Intercourse
~ 75% Effective
Yuzpe Method: Ovral 2 tabs po now and 2
tabs 120 later
May Cause Nausea
Consider Dispensing at Yearly Visit
Special Circumstances
Postpartum/Postabortion:
IUD, Progestins, Combination OCPs*
Anticonvulsant/Antibiotic Use:

TCN Probably OK
Most Anticonvulsants Impair Efficacy
of Hormonal Contraceptives

* may affect lactation before milk flow established

Summary
A Limited, but Diverse Range of
Contraceptive Options Exist in the USA
Barrier Methods Tend to Have Higher
Failure Rates than Hormonal Methods
and the IUD
The IUD is Underutilized
All Methods have Risks and May Not be
Appropriate for all Patients