Download Contraception Choices 2017

4/19/2017
Contraception
Choices
2017
Tandra Cadigan, D.O.
Obstetrician/Gynecologist
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No Disclosures
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Graduated from Western University of Health Sciences with a
Doctor of Osteopathic Medicine in June, 1984, Pomona, California
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Internship at Pontiac Osteopathic Hospital - July 1984 to June
1985, Pontiac, Michigan
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Residency at Providence Hospital in Obstetrics/Gynecology - July
1985 to June 1989, Southfield, Michigan
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Private practice in Newport Beach, California in Obstetrics and
Gynecology from July 1989 to the present.
Disclosures
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INTRODUCTION
The Pope disapproves of it. Teens are confused by it. it is a politically charged health issue.
Estimated 62% of American women ages 15 to 44 use some form of contraception.
It is easy to be confused by all the birth control choices available. Now we have more choices than
ever—but more choices also means there is a lot to consider. So how can the physician choose
which pregnancy prevention is right for the patient. The most important step in deciding is how the
different birth control options will affect the health of our patients. Factors like hypertension, smoking
habits, history of breast cancer, and blood clots should all be considered.
It is also important that the patient schedule an appointment with their physician to consider all the
many choices available today.
It is easy for our patients to be confused; should one take a progesterone-only pill or the mainstream
combination. What about the IUD? The implant? Is the female condom as effective as the male?
We are going to discuss the many birth control options, their pros and cons, effectiveness and method
of action.
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FERTILITY AWARENESS
If the patient knows her cycle and is regular, she can prevent pregnancy through fertility
awareness by tracking her cycle on a calendar, monitor her mucus, which thins at mid
cycle, and abstaining at the fertile times. This does not prevent STD’s so this method
should be used by women in a stable relationship.
Pros: no prescriptions, devices, and it is natural.
Cons: Patient needs to be committed to monitor her cycle. Sperms can stay active for
up to six days after sex, a barrier method should be used six days before the patient
ovulates and six days after.
Failure rate is about 25%.
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ABSTINENCE
Ceasing sexual activity is the one birth control method that cannot
fail.
Pros: Refraining from sex is the only foolproof way to prevent
pregnancy.
Cons: This option is not feasible for all patients—nor is it easy. We
are all human beings and we all have a sex drive. A back-up method
should be available.
Breast feeding, outer course, and pull-out methods are also used by
our patients. Their effectiveness is debated.
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MALE AND FEMALE CONDOMS
Male condoms are a birth control mainstay. They are the ONLY choice that not only prevents
pregnancy, but diseases and infections as well. Tell your patients that if there is a risk that their
sexual could pass on a STD, condoms are a must. The male condom being the most popular. A
spermicide can be used with the condoms. However, spermicide alone only prevents pregnancy
for about 72% of women. Male condoms such as Durex, Lifestyle, and Trojons, protects against
pregnancy and STD’s. Avoid latex if partner has a latex allergy. The male should use only oilfree lubricants such as K-Y. Lambskin condoms do not protect from STD’s.
Cost. Free to $1.00
82% effective
Female condoms such such as Protective and Reality can be inserted up to eight hours before
sex. This should be avoided unless the patient is in a long term relationship. No protection from
STD’s. Some women complain that the female condom are awkward to insert and can create
funny noises.
Cost. $2-4 79% effective
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DIAPHRAGM AND SPONGE WITH SPERMICIDE
These are barrier methods that block sperm from entering the uterus. Physicians fit the patient and should be checked every one or two years to
make sure no holes have developed. Diaphragms are used with a spermicide. If the patient gains or loses weight the diaphragm must be re-fitted.
Common diaphragms are the Milex Wide Seal, Ortho-All Flex, and Semina.
Pros. The patient may insert her diaphragm anywhere from just before sex and up to 24 hours before sex. This method is safe in women with a
history of breast cancer.
Cons. To be the most effective, it should be used with a spermicide and left in place for six hours after the patient has had sex. To avoid an UTI, the
patient can urinate after sex. Spermicides can increase the risk of obtaining HIV, so do not use if there is a risk. The diaphragm should be avoided in
women who have a tendency of fluctuating weight. If the patient has a history of Toxic Shock Syndrome, do not use.
Cost. $80
88% effective
The sponge is a soft-like pillow used with a spermicide.
Pros. The sponge is over the counter, small, and will not effect a woman’s hormones.
Cons. Must be used with a spermicide.
Cost. $4-6 76-88% effective Cervical cap is $5-7 80% effective
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THE PATCH AND THE RING
The patch and the ring are both hormonal methods containing both estrogen and progestin similar to the pill. However,
the patient does not have to take a pill every day. The patch is a small piece of plastic that sticks on the patient’s
abdomen, buttocks, arm, or torso and is replaced weekly. Oath Evra is an example. The patch has 60% more estrogen
that the low dose pill, so avoid if patient has a history of blood clots. The patch is good for one week.
Cost. Free to $80 92% effective
The ring is a small flexible device that is placed in the vagina and left for three weeks at a time and is then taken out for for
one week a month. Nuva ring is one example.
Pros. Both of these birth control methods share all the benefits of the combination pills—they are just more convenient for
the patient. They may also be used continuously to allow the patient to skip menses.
Cons. The patch can cause skin reactions in some patients. And like the pill can cause side effects such as spotting,
headaches, bloating, and breast tenderness. The patient should not use if they had a history of blood clots, uncontrolled
high blood pressure, and migraines. The ring has additional side effects of vaginal discharge or vaginal irritation. A;lso,
women that smoke and are 35yo or older should not use combination birth control. Caution should be used when there is
a history of breast cancer.
Cost. Free to $80 92% effective
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BIRTH CONTROL PILLS
There are a lots of birth control pills for our patients to choose form—including ones that are progestin only. There are also many generic
OC’s on the market and it can be difficult to prescribe the same pill year after year as the patient’s insurance companies change the choice
that the patient is offered. All combination pills contain estradiol, it is the progesterone component that varies. Each producer of OC’s
believe that their product is the best. So listen to your patient and the one that she likes is the one that we should prescribe. The progestin
only pill such as Micronor, Nora-BE, and Orvorette are safe for smokers, DM, CVD, patients with a history of blood clots, and breast-feeding
moms. But it is very important to take the pill every day at the same time, if there is a three hour lapse a back-up method should be used.
This pill thickens the mucus to prevent sperm migration and affects the ovaries in releasing eggs.
Pros. If the patient remembers to take her BC pill as prescribed, the failure rate can be as low as 1%. Combination pills can help with
menstrual cramps, lighter menses, and fewer symptoms of premenstrual syndrome. The combo pill may also provide protection against
pelvic inflammatory disease, infections, endometrial cancer, and ovarian cancer. The progestin-only pill are ideal for women who are
breastfeeding because they do not effect milk production . They are safer for women who have a history of blood clots or have uncontrolled
high blood pressure. Both types of contraception help regulate the patients menses, and the patient can use them to control how many
periods they have in a year. Birth control combo pills can decrease acne.
Cons. The pill has an 8% failure rate—because it is difficult for some women to remember to the pill regularly. If the patient is on a
progestin-only pill, it is important that they take this pill at the same time every day. However, if a patient misses three or more of the
combination pills a back-up method should be used. The pill may cause spotting, breast tenderness, nausea, and diminished sex drive.
Also reported are weight gain, anxiety, and depression. These side effects usually resolve after three months. The combo pills can
increase the risk of blood clots in the legs and increase the risk of stroke if the patient smokes. OC’s that contain estrogen can have
decrease efficacy if drugs such as Rifampin, and griseofulvin are used. These medications reduce the levels of estrogen by enzymes in the
liver which can result in an unwanted pregnancy.
The new Lo Low OC’s on the market contain just 10 micrograms of estradiol have demonstrated an effective pregnancy prevention.
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Treatment with the LoLow Loestrin should be stopped if a patient develops a blood clot and is at least four weeks before and two
weeks after major surgery. Patient should not take Lo Loestrin earlier than four weeks after having a baby or if breast feeding.
Monitor liver if skin becomes yellow and stop the pill. If a patient is pre-diabetic or diabetic, we need to monitor the patient and reevaluate if there are changes in her HA or patient experiences irregular bleeding. There is a serious increase risk of blood clots,
stroke, and heart attacks. If the patient is obese this is probably not the best choice.
Another choice is the extended-cycle pill such as Lybrel which stops menses for a year but must be taken every day, Seasonale
and Seasonique which allows menses every 3 months. However, no long term research has been done to show safety.
Birth control pills do not protect the patient from STD’s, including HIV.
Costs. Free to $50 92-99% effective.
TAKE HOME MESSAGE: If pregnancy prevention methods contain estrogen, do not give to a woman with a history of blood clots.
ACNE in adolescents and long acting reversible birth control methods:
Examining the impact of contraception on acne in adolescents is clinically important because acne affects about 85% of
adolescents and contraception may influence the course of the acne disease. The combination pill causes a significant
improvement in acne. By contrast, the long acting levonorgestrel-releasing IUD and the etonogestrel contraceptive implant my
exacerbate acne.
The estrogen-progestin contraceptive improve acne by two mechanisms. Primarily by suppressing pituitary luteinizing hormone
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hormone secretion, thereby decreasing ovarian testosterone production. Also, the combo OC’s increase liver production of sex hormone-binding globulin thereby increasing
bound testosterone and decreasing free testosterone. The decrease in ovarian testosterone production and the increase of SHBG-bound testosterone reduce sebum production
resulting in acne improvement. The US Food and Drug Administration has approved four combo pills for acne treatment: Estrostept, Ortho-Tri-cyclen, Yaz, and Be Yaz.
The levonorgestrel intrauterine devices (LNG-IUD), including levonorgestrel systems Mirena, Liletta, Skyla, and Kyleena and the etonogestrel implant (Nexplanon) are among the
most effective contraceptives available to woman and are excellent choices for the adolescent. There has been an increase in the use of LARC. Tn 2002, 1.3% of women ages
15-24 used an IUD or implant, and this percentage increased to 10% by 2013, and continues to increase. In a recent three-year prospective study of more than 2,900 women the
implant was associated with a higher rate of reported acne. In a retrospective review of 991 women who used the implant 24% requested that the implant be removed. The most
common reasons were bleeding disturbances, 45%, worsening acne, 12%, and desire to conceive, 12%. Similar studies have shown a statistically significant worsening of acne
with the use of implants and hormone IUD’s. Clinicians planning on switching a patient from an oral combination pill to an implant or progestin IUD need to evaluate the patient’s
current acne symptoms and acne history as this is important.
Treatment of acne include topical retinoids, topical antimicrobials, and oral antibiotic.
A. Topical retinoids: Adapalene, Tretinon, Tazarotene
B. Topical antimicrobials: Benzoyl peroxide, Clindamycin, Azelaic acid, and Dapsone
Oral Antibiotics: Doxycycline 100mg once daily, Minocyclie 50mg once daily, and Tetracycline 500 twice daily.
In adolescents with a mild acne a topical retinoid or benzoyl peroxide can be used together or separately. Referral to a dermatologist is recommended for moderate to severe
acne. Therefore, if the physician chooses the implant or the progestin IUD,
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IUD, the patient’s acne would be adequately treated. In adolescents who do not tolerate the progestin-IUD or implant, the copper
IUD is a good choice and can be paired with the combination birth control pill for there acne. Adolescents are more likely to
continue with LARC choices then with the oral birth control pills, and this results with substantially lower pregnancy rates in this
patient population. LARC is recommended as first-line contraception for adolescents by both the American Academy of Pediatrics
and the American College of Obstetricians and Gynecologists. In choosing contraception for your adolescent patients the risk of
unintended pregnancy should be weighed against the risk of acne and other potential side effects. Do not select a contraceptive
based on the presence or absence or acne disease. Because patients with mild and moderate acne-disease can be treated with
topical retinoids and/or antimicrobial agents.
HORMANAL IMPLANTS
A piece of plastic (about the size of a match stick) is inserted just below the skin. This form of contraception contains progestin. It
is inserted by the physician just under the skin in the upper arm and prevents pregnancy for three years. Nexplanon is a LARC—
LONG ACTING REVERSIBLE CONTRACEPTIVE containing 68 mg of etonogestrel. All health care providers performing
insertions and/or removals should receive instructions prior to inserting or removing the implant.
Pros. The patient does not need to worry about birth control for three years. This method is also visible. The implant should be
inserted subdermallly and be palpable after insertion. If unable to palpate then it must be removed as failure to remove may result
in comprised fertility and ectopic pregnancy. Be alert to the possibility of an ectopic pregnancy in women using the implant who
become pregnant or complain of lower abdominal pain. There have been reports of women using the implant experiencing
pulmonary emboli, DVT, MI, and stroke. Because of the risk of thromboembolism associated with pregnancy and immediately
following delivery, implants should not be used prior to 21 days postpartum. It is as effective as an IUD. If the patient desires
pregnancy she can just have the implant removed. The birth control implant was first used in Indonesia in the 1970’s.
Cons. Most women will experience irregular bleeding throughout the first year, but eventually the bleeding will stop. If irregular
bleeding is a problem, estrogen can be given to counteract it. Overweight women should avoid the implant. Baware of the
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Be aware of other serious complications, adverse reactions, or drug interactions and remove if jaundice occurs, remove if blood
pressure rises significantly and becomes uncontrolled. Pre-diabetics and diabetic women should be monitored carefully. If a
woman becomes depressed consider removing the implant. Most common adverse reactions are HA 24.9%, vaginitis 14.5%,
weight gain 13.7% acne 13.5%, breast pain 12.8%, abdominal pain 10.9%, and pharyngitis 10.5%. Drugs or herbal products that
induce enzymes, including CYP3A4, may decrease the effectiveness of the implant. Women who weigh more than 130% of their
ideal weight maybe at risk for pregnancy because serum concentrations of etonogestrel are inversely related to body weight and
decrease with time.
Cautions: If an implant user experiences a pregnancy that is ectopic or intrauterine and undesired, the device may be left in and
use continued after the pregnancy has been terminated. Research has demonstrated that with a medical abortion, the implant
does effect the termination. For women with a desired pregnancy, the device should be removed as soon as possible. There is no
known teratogenic risk associated with the implant. If the woman desires pregnancy and the implant is not palpable, appropriate
imaging is needed. Ultra-Sonography with a high frequency linear array transducer ( 10 MHZ or greater) may allow an
experienced radiologist to identify the implant. MRI or plain x-ray may also be used to detect a barium-containing device. MRI
can be used to locate a non-barium containing implant. Removal is aided by U/S guidance in an operating room by an
experienced surgeon who is familiar with the anatomy of the upper arm .
Important safety information: Implants should not be used in some who have a known pr suspected pregnancy , history of
thrombosis or thromboembolism disorders, liver tumors or active liver disease, undiagnosed genital bleeding, breast cancer, or
progestin-sensitive cancer, or an allergy to any of the components of the implant.
Cost. Free to $800 $300 for removal
99% effective.
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THE IUD
The IUD which is inserted in the uterus and comes in copper (paraguard) which prevents sperm from reaching the egg and the
IUD containing progestin such as Mirena and the new IUD form Allergen called Liletta containing 52mg of levonorgestrel.
Pros. The IUD is very effective—pregnancy occurs in less than 1 in a 100 women who use one. It is invisible from the outside,
and the patient does not need to use a spermicide. The copper IUD can be left in for 12 years, and the progestin containing IUD
for five years. The copper IUD can even be used for emergency contraception if it is inserted within five days of unprotected sex.
Another benefit of the IUD is that although long-term, it is reversible, and the patient may become pregnant after having it
removed.
Cons. IUD’s may cause an increase on cramping. If patient has a STD at the time of insertion, there is a risk of PID. A vaginal
culture is recommended prior to insertion with the results known. In Europe, The IUD is the most common form of pregnancy
prevention and it the US it is the BCP.
Challenges with the IUD: IF the patient becomes pregnant with an IUD in place which occurs less than 1%, obtain an U/S to
determine the location of the pregnancy and the placement of the IUD. If it is an ectopic pregnancy, it may be managed medically
or surgically with the IUD in place. If an intrauterine pregnancy is found, and is undesired, the IUD may be removed at the time of
surgical abortion or before the initiation of a medical abortion. With a desired pregnancy, if the strings are visible, remove the IUD
with gentle traction. If the IUD is left in place, the risk of spontaneous abortion is significantly increased.
For insertions of a nulliparous woman who is fearful of the pain there are several things we can do. Place lidocaine into or on the
cervix or give Tramadol 50mg one hour before insertion. If the strings cannot be located after postpartum insertion, the location of
the IUD is important. If the strings cannot be located with a cytobrush in the cervical canal then radiological techniques are
needed to locate the IUD. U/S and x-ray may be needed. All IUD’s used in the US are radiopaque. When found operative
removal is indicated. If the IUD is not seen on x-ray, expulsion is the most likely cause. Explosion is more common in porous
users, women younger than 20, placement following a delivery, or second trimester abortions. Also, if the strings are not
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the strings are not visible and the patient requests IUD removal, confirm location with an U/S and use alligator forceps or an IUD hook for
removal. If the IUD is malpositioned, ACOG advises that the IUD be removed.
Cost. Free to $800
99% effective.
HORMONE INJECTIONS
An injection of progestin (depo-provera), in the arm offers women pregnancy prevention for three months at a time. It blocks ovulation, and
also makes it more difficult for sperm to travel because of an increase in cervical mucus.
Pros. When the hormone injection is administered properly by a healthcare provider, fewer than 1 in 100 women will get pregnant. The
patient does not have to think about birth control every day, every week, or even every month. This injection may reduce the risk of uterine
cancer, and protect the patient from PID, according to the American Congress of Obstetricians and Gynecologist ACOG.
Cons. The patient has to go to the physician to obtain the injection, and the injection tend to cause more irregular bleeding than the pill,
patch, or ring, particularly during the first three to six months. Prolonged use can lower the patient’s bone density. Therefore, a bone
density test should be done if the patient has been on this method for five continuous years. However, bone loss is reversible once the
patient stops using this method. If the patient desires to become pregnant, she must plan ahead, because it can take anywhere from 3 to 18
months to begin ovulating again.
Cost. Free to $20
98% effective
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TUBAL LIGATION FOR WOMEN
This is considered a permanent birth control choice. Tubal ligation involves closing the uterine tubes to prevent the patient’s egg
from being fertilized. There is also, Essure which is a non-surgical method which accomplishes the same thing. A small coil is
inserted into the tubes blocking sperm transport.
Pros. Female sterilization is generally a safe form of contraception and has no effect on hormone production. It is nearly 100%
effective. It may lower the risk of acquiring ovarian cancer.
Cons. The tubal ligation requires an operation requiring anesthesia, and as surgery, has some of the associated risks: reactions
to pain medications, damage to the bladder or bowel, and pelvic pain afterwards, notes the Mayo Clinic. This birth control method
is considered permanent, so the patient must be sure that she does not want more children before opting for this procedure. Like
a vasectomy, reversing sterilization is expensive and not guaranteed.
VASECTOMY FOR MEN
Vasectomy is a simple procedure. Through a tiny incision, the surgeon closes the times that carry the man’s sperm, preventing
them from leaving his body.
Pros. A vasectomy is almost 100% effective for contraception, the tubes grow back together in about 1 in 1,000 men. This
permanent form of birth control carries few risks, requires a few days recovery , and has no effect on a man’s sexual function.
Cons. The patient will have to use a back up method for about three months after surgery to be sure all previously made sperm
have been ejaculated. A vasectomy may increase the risk of prostate cancer, and it is permanent. Although the surgery can be
reversed is some cases, it is expensive and success is not guaranteed.
There is a new birth control method for men in the pipe line called Adjuden. It is a pill for men which will prevent the sperm from
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from maturing but it is still years away before being available.
EMERGENCY CONTRACEPTION
Emergency contraception is a back up for regular birth control. Plan B contains a higher dose of the same synthetic hormones found in the combination pill. It
works best if taken within 72 hours of unprotected sex, but may work up to 5 days later. Plan B also known as the morning after pill, is available “over the counter”
at most pharmacies, but only for women 18 years or older. Minors need a prescription. Levonorgestrel and ulipristal are typically found in Plan B pills. Next
Choice, PlanB, and Plan B one-step are all emergency contraceptives. The Yuzpe method is two doses of combination pills.
Cost. Free to $80 98% effective.
The copper IUD can be inserted into the uterus 5 to 7 days after unprotected sex. This method is expensive and may cost up to $500. It is good for 10 years.
EARLY ABORTION TERMINATION OPTIONS
Aspiration and medical abortion using Mifepristone and Misoprostol are choices in termination. Medical abortion is recommended to be given in the 7 to 9 weeks
of pregnancy. This method requires at least two visits to the physician over several weeks. One medicine is given to the patient on the first visit, typically
Misoprostol which softens and opens the cervix and triggers uterine contractions. Misoprostol can be used alone but it is more effective when used with another
medicine such as mifepristone or RU-486.
BIBILOGRAPHY
OBG Management January 2017. Sara Newmann, MD , Assistant professor in the department of Ob/Gyn and reproductive Sciences at U of California, San
Francisco, author of The Best and Worse Birth Control Options, Drug literature.for Nexplanon.
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