Lecture 5 Contraception & Sterilization - Women's Health

Autonomy - Why Contraceptives Matter?

1. Control reproductive health & timing of pregnancies to improve maternal and infant health outcomes

2. Informed choices about #, spacing and timing

3. Reduce risk of STIs

4. Improved mental and emotional health

Societal Benefits - Why Contraceptives Matter?

1. Economic stability

2. Educations & employment opportunities

3. Management of population growth and resource distribution for sustainable development

Contraceptive Counseling

1. Patient centered, shared decision making

2. Identify contraceptive need

3. Assess medical conditions

4. Elicit patient preference

5. Education on use of selected method

Tier 1 Effective Contraceptive Methods

1. Implant

2. Vasectomy

3. Tubal occlusion

4. IUD

Tier 2 Effective Contraceptive Methods

1. Injectables

2. Pill

3. Patch

4. Ring

Tier 3 Effective Contraceptive Methods

1. External condom

2. Fertility awareness-based methods

3. Diaphragm

4. Sponge

5. Withdrawal

6. Internal condom

7. Spermicides

Hormonal Contraceptive Mechanisms

Ovulation Suppression via Estrogen and Progesterone

Estrogen's Role in Ovulation Suppression

Suppresses FSH prevention folliculogenesis

Progesterone's Role in Ovulation Suppression

1. Affects endometrium making it less suitable for implantation

2. Cervical mucus thickening

3. Impairs tubal motility and peristalsis

Non-hormonal Contraception Mechanisms

Mechanical, chemical, or temporary barrier between the sperm and egg

Fertility Awareness Method

a method of charting ovulation; focusing on day 14 of typical 28 day cycle

Fertile window

Two days preceding ovulation shows increase probability of pregnancy from unprotected intercourse (25%-28%)

Cycle Length

in 95% of menstrual cycles, ovulation occurs in the 4 days before or after the midpoint of the cycle

Cervical Secretions

Abundant, clear, wet, stretchy cervical secretions occur immediately before, during, and immediately after ovulation

Basal Body Temperature

1. increase in basal body temp by 0.5 degrees F

2. 1-2 days after LH surge

Ideal Candidates for Fertility Awareness-Based Method

1. Compliant

2. Abstain from sex/use barriers on fertile days

3. Communicate with partner

4. Supportive partners

Contraindications for Fertility Awareness-Based Method

1. Irregular cycles

2. Interruption of cycles (postpartum/delivery, pregnancy loss, abortion)

3. Inability to trace physiologic changes

4. Lack of a supportive partner

Efficacy of for Fertility Awareness-Based Method

Pregnancy rates around 25%

How long does ovulation last?

Fertile 3 days before and about 2 days after day 14

Standard Days Method for Fertility Awareness Based Method

Uses fertile days using 2 sets of probabilities (pregnancy w respect to ovulation and ovulation occurs at the midpoint of the cycle

Benefits of Standard Days Method

1. Easiest to teach

2. Fewest days requiring abstinence or barrier protection

When is Standard Days Method appropriate?

Appropriate when menstrual cycle is. b/t 26-32 days

How long should one avoid unprotected intercourse with the Standard Days Method?

Day 8-19 (~12 days)

Cervical Mucus/Ovulation Method

1. Dry after menstruation

2. Subsequently - thick, sticky mucus appears

3. Becomes thin, stretchy, clear cervical mucus

4. Last day of wetness = peak = ovulation

5. Fertile period within signs of mucus and continues until 4 days after the peak day

Spinnbarkeit

Thin, stretchy clear cervical mucus

Disadvantages to Cervical Mucus/Ovulation Method

More time to teach

How long should one avoid unprotected intercourse with the Cervical Mucus/Ovulation Method?

~13-17 days each cycles

Examples of the Cervical Mucus/Ovulation Method

1. TwoDay Method

2. Billings Method

3. Creighton Method

Multimodal Method - Fertility Awareness-Based Methods

1. Symptothermal method (changes in cervical secretions & BBT)

2. Device-assisted methods (mini-microscopes & computers)

3. Fertility monitor (Clearblue)

4. Computer apps (Natural Cycle; Clue)

5. Lactational amenorrhea (up to 6 mo of amenorrhea with breastfeeding; temp. BBT)

External Condom Efficacy

1. 2% pregnancy with perfect use

2. 13% with typical use

Internal Condom Efficacy

1. 5% pregnancy with perfect use

2. 21% with typical use

Benefits of External/Internal Condoms

1. Reduce risk of pregnancy

2. Reduces STI transmission, inc. HIV

3. Reversible

4. Easily accessible

5. Inexpensive

6. Discrete

Disadvantages of External/Internal Condoms

1. Device failure (break, slip, invagination)

2. Latex allergy

3. Decreased sensitivity/satisfaction

Diaphragms Efficacy

1. 6% pregnancy with perfect use

2. 12% with typical use

Cervical Cap Efficacy

1. 13-16% nulliparous women

2. 23-32% multiparous women

Use of Diaphragms/Cervical Caps

Spermicide (nonoxynol-9) applied inside before insertion and reapplied after each sexual encounter

Contraindications of Diaphragm/Cervical Caps

1. Pelvic organ prolapse

2. Allergy with material

3. Frequent UTIs or h/o toxic shock syndrome (TTS)

4. Increased risk for HIV infx acquisition (vaginal irritation)

Complications of Diaphragms/Cervical Caps

1. UTI

2. Vaginal irritation

3. TSS

OCP Route

Oral

OCP Dosing

1. Monophasic - same E-P dose for active pills

2. Multiphasic - varied dose of hormones; reduced SE & breakthrough bleeding

OCP Regimen

1. Cyclic

2. Can be taken until menopause age (age 50/51)

Cyclic Regimen of OCPs

1. 21 active pills + 7 placebo pills (withdrawal bleed)

2. 24/4, 84/7, continuous - reduced SE

MOA of OCPs

1. Inhibits ovulation

2. Alters cervical mucus making it more hostile to sperm

Risk Associated with OCPs

1. +/- increased risk VTE/CVA

2. depending on age, obesity, and smoking status

Side Effects of OCPs

1. Breast tenderness

2. N

3. Bloating

4. Mood changes

5. Breakthrough bleeding

OCPs Benefits

1. AUB, PCOS, PMS, PMDD

2. Endometriosis, dysmenorrhea

3. Ovarian cysts

4. Hyperandrogenism

5. HRT for hypogonadism or premature ovarian insufficiency

6. Cancer risk reduction (endometrial/ovarian)

7. Improved bone density

DDI with OCPs

1. Antiseizure meds (topiramte)

2. Rifampin

3. Doxycycline

4. Griseofulvin

5. St. John's Work (decrease efficacy)

Avoid OCPs in

1. >35 & smokes >15 cigs daily

2. CVD RF

3. HTN >160/100

4. VTE (unless on coag)

5. H/o ischemic heart dz, stroke, valvular dz

6. Breast cancer

7. Liver dz

8. Migraine with aura

9. DM > 20 yr duration w or w/o nephropathy/retinopathy/neuropathy

10. Early postpartum

Quick Start Approach OCPs

1. Negative urine pregnancy

2. Consider LMP & timing of last ep of unprotected sex

3. Use back-up method for first 7 days

Stopping OCPs

1. Regular menses returns 30 days after stopping

2. Fertility returns 90 days after stopping

Transdermal Patch Types

1. Ethinyl estradiol (35) - noelgestromin (150) (Xulane)

2. Ethinyl estradiol (30) - levonorgestrel (120) (Twirla)

Frequency of Transdermal Patches

1. Apply weekly to lower abd, buttocks, upper back for 3 weeks with 1 week off

2. Avoid extended and continuous regimens

Benefits of Transdermal Patches

1. Same as combined OCP

2. Weekly dosing

3. Non-oral route

Side Effects of Transdermal Patches

1. Same as combines OCP

2. Skin irritation

Risks of Transdermal Patches

1. Same as combined OCP

2. Slight increase in risk of thrombosis

MOA of Transdermal Patches

Same as combined OCP

DDI of Transdermal Patch

Same as combined OCP

Avoid Transdermal Patch in

1. Same as combined OCP

2. BMI >/= 30

Vaginal Ring Route

Flexible device inserted vaginally

Types of Vaginal Ring

Etonogestrel (120) / Ethinyl estradiol (15) (NuvaRing)

Frequency of Vaginal Ring

1. Inserted vaginally for 3 weeks with 1 week removed and discarded

2. Continuous regimen is available

Benefits of Vaginal Ring

1. Same as combined OCP

2. Avoids daily compliance

3. Private

4. Less impact on insulin resistance

Side Effects of Vaginal Ring

1. Same as combined OCP (less intense)

2. Vaginitis

3. Leukorrhea

Risks, MOA, and DDI with Vaginal Ring

Same as combined OCP

Avoid Vaginal Ring in

1. Same as combined OCP

2. AUB

3. Likely or unconfirmed pregnancy

4. Early postpartum

5. Lactating pts: delay insertion until 30 days PP

Progestin Only - OCP Frequency

1. Norethindrone (28 pills)

2. Drospirenone (24-4 pills)

3. Continuous regimen

Benefits of Progestin Only - OCP

1. Protects against endometrial/ovarian cancer

2. Lower ectopic risk

Side Effects of Progestin Only - OCP

1. Breast tenderness

2. Nausea

3. Bloating

4. Mood changes

5. Ovarian cysts

6. Breakthrough bleeding

Risks with Progestin Only - OCP

Safer for pts with CVD risk

Who are good patients for Progestin Only - OCP?

1. Breastfeeding women

2. Women with contraindications to estrogen

Avoid Progestin Only - OCP in

1. Known pregnancy

2. Breast cancer

3. AUB

4. Severe liver dz

DDI Progestin Only - OCP

1. Antiseizure meds (topiramate)

2. Doxycycline

3. Rifampin

4. Griseofulvin (Decrease efficacy of POP)

6. Lamotrigine (compatible with POP use)

MOA of Progestin Only - OCP

1. Suppression of ovulation

2. Endometrial lining more hostile for implantation

3. Thickening of cervical mucus

4. Negative effects on tubal motility & peristalsis

Implant Route

4 cm x 2mm rod implanted in upper inner arm

Implant Frequency

1. Continuous contraception x3yrs etonogestrel (Nexplanon)

2. Could possibly go up to 5yrs

Benefits of Implant

Most effective form (0.05%)

Side Effects of Implant

1. Local site irritation

2. Breakthrough bleeding

Risks Associated with Implant

Safer for pts with CVD risks

MOA of Implant

1. Endometrial lining more hostile for implantation

2. Thickening of cervical mucus

DDI with Implant

1. Antiseizure meds (topiramate)

2. Doxycycline

3. Rifampin

4. Griseofulvin (Decrease efficacy of Progesterone)

6. Antiretroviral drugs

Avoid Implant in

1. Known pregnancy

2. Breast cancer

3. AUB

4. Severe liver dz

What patients are good for implant?

1. Breastfeeding women

2. Women with contraindications to estrogen

IUD Route

Intrauterine device placed in uterus

Frequency of IUD

1. Levonorgestrel IUD (mirena) for 5yrs

2. Non-hormonal copper IUD (paragard) for 10yrs

Benefits of IUD

1. Highly effective

2. No daily compliance

3. Rapidly reversible

4. Long-acting

5. Private

6. Reduction of cervical/ovarian/endometrial cancer

7. Cost-effective

8. Can be used as emergency contraception

Side Effects of IUD

1. Cu - longer, heavier menses within 6mo

2. LNG - breakthrough bleeding

MoA of IUD

1. Foreign body effect -> sterile inflammatory rxn

2. Cu -> cytotoxic inflammatory response in endometrium

3. LNG -> thickened cervical mucus

DDI of IUD (LNG)

1. Antiseizure meds (topiramate)

2. Doxycycline

3. Rifampin

4. Griseofulvin (Decrease efficacy of Progesterone)

6. Antiretroviral drugs

Avoid IUD in pts

1. Known pregnancy

2. Breast cancer in LNG

3. AUB

4. Severe liver dz

5. Uterine structural abnormalities

6. Pelvic infection

7. Wilson's Dz/Cu allergy

Injectable DMPA Route

IM or SubQ

Frequency of DMPA

Depot medroxyprogesterone acetate 150mg IM every 13 weeks

Benefits of Injectable DMPA

1. No daily compliance

2. Rapid reversible

3. Long-acting

4. Private

5. Cost-effective

6. Reduction of sickle cell crisis

7. Reduction in anemia

8. Improved fibroids

9. Reduced risk of endometrial cancer

Side Effects of Injectable DMPA

1. Breakthrough bleeding

2. Reduction of bone density

Recommendation for Patient Taking DMPA

Supplement with vitamin D and calcium

Risks Associated with Injectable DMPA

1. possible increase in VTE and CV risk

2. Possible increase risk of DM

MOA of Injectable DMPA

Thickened cervical mucus

DDI of Injectable DMPA

1. Antiseizure meds (topiramate)

2. Doxycycline

3. Rifampin

4. Griseofulvin (Decrease efficacy of Progesterone)

6. Antiretroviral drugs

Avoid Injectable DMPA in pts

1. Known pregnancy

2. Breast cancer

3. AUB

4. Severe liver dz

5. Long term use of steroids

6. Use of aminoglutethimide (Cushing's tx)

Emergency Contraception

1. Ulipristal acetate (UPA) 30 mg

2. Oral LNG 1.5 mg (plan B)

3. Combined OCP -Yuzpe method

4. Cu IUD (Paragard)

5. LNG IUD (Mirena)

Ulipristal Acetate (UPA) for Emergency Contraception

1. Take within 5 days of UPI

2. Prevent ovulation

3. Available with Rx

4. 1.2-1.8% efficacy pregnancy rates

5. Should not be used with other progestin-containing contraceptives