Contraception

1. Contraception Potpourri

2. Hormonal Contraception How It Works, Various Forms

3. Hormonal Contraceptives: Mechanism of Action • Synthetic estrogen and/or synthetic progesterone • Combination hormone contraceptives halt ovulation • No egg = no pregnancy • HybridMedical video: Ovulation (YouTube)

4. Hormone-Based Contraception • Estrogen • Usually ethinyl estradiol • Progestin • Many types • Types vary in terms of side effects • Blood lipids • Break-through bleeding • Weight gain/metabolism • Acne Source: Dawn Stacey, About.com

5. Estrogen • Estrogen suppresses development of follicle within ovary • Estrogen changes the endometrial lining, making the uterine environment less accommodating to a fertilized ovum

6. Estrogen • Estrogen makes progestin activity stronger • Progestin manipulates one of the hormones responsible for ovulation • So, even if estrogen does not completely prevent follicle development, it works with progestin to prevent ovulation

7. Progestin • Progestin thickens cervical mucus • Thicker mucus hampers sperm movement • Progestin also changes the endometrial lining • Reduces likelihood for egg implantation • Progestin-only methods may not inhibit ovulation • Varies from one cycle to another • Method dependent (Depo-Provera inhibits ovulation, minipills may not) • Effectiveness due to cervical mucus, endometrial changes

8. Hormonal Contraception: Contraindications • Women with history of venous clots, coronary artery disease, stroke, diabetes with blood vessel damage, high blood pressure, breast cancer, abnormal bleeding, liver problems • Smoking • Obesity? (pills = most controversy; IUD, implant recommended, per Edelman et. Al., uptodate.com)

9. Ortho Evra • “The patch” • Beige plastic patch applied to the skin • Once a week for three weeks • Stomach, upper arm, upper torso • First day of menses or first Sunday after period starts • Releases estrogen and progestin

10. Ortho Evra • Cost: Included with insurance; average wholesale price is ~$0-80/month (Planned Parenthood) • Patch should be applied on same week day • Effectiveness: 99%

11. Ortho Evra: Side Effects • Breast tenderness (~20%) • Headache • Sensitivity to adhesive • Nausea • Menstrual cramping • Increase in HDL, LDL, triglycerides • Upper respiratory infections • Increased blood clot risk vs contraceptive pills Source: OrthoEvra.com

12. NuvaRing • Insertion of ring into vagina • Remains in place for three weeks • Combination method: estrogen and progestin released • Cost: $0-80/month (Planned Parenthood) • Insertion (YouTube, 0:45-1:20)

13. NuvaRing: Side Effects • Vaginal irritation • Nausea • Weight gain • Irregular bleeding/spotting • Rash • Serious, rare: blood clots, gallbladder disease, cancer, liver growths, pancreatic inflammation (triglycerides), cardiovascular incidents

14. Nexplanon/Implanon • Implanon approved by FDA in 2006 • An implant • One rod (Norplant-six) • Inserted under skin, inner arm • Can feel implant • Low-dose progestin release • Good for three years

15. Nexplanon/Implanon • 1.5 inches in length • Effectiveness: 99% • Cost: Included with insurance; $0-800 (Source: Planned Parenthood) • Upon removal, fertility returns to normal within several weeks • Sensitive insertion video (YouTube, 2:08)

16. Nexplanon/Implanon: Side Effects • Irregular bleeding • Headache • Depression • Breast tenderness • Acne • Weight gain

17. Depo-Provera • Approved by the FDA in 1992 • Progestin-only contraceptive for females • Hormone is injected every three months • Arm • Buttocks • Depo-Provera works by preventing ovulation, thickening cervical mucus, altering endometrium

18. Depo-Provera • Effectiveness • Protection immediate if first shot occurs during first five days of period; otherwise, use other contraceptive method for two weeks • Greater than 99% effectiveness (MayoClinic.com=97%) • Cost: quarterly doctor visit + $0-100 quarterly injection (Planned Parenthood)

19. Depo-Provera: Side Effects • Headaches • Dizziness • Nausea • Breast tenderness • Fatigue • Weight gain • 5 pounds or more after one year • Appetite change

20. Depo-Provera: Side Effects • Abdominal pain • Acne • Mood changes • Bloating • Menstrual irregularities (lighter, heavier, cessation) • Bone density loss • Unclear whether condition will improve when injections stop • Calcium supplements • Weight bearing exercise advocated • FDA’s “black box” warning in 2004 • Avoid long-term use (> 2 years) • Association of Reproductive Health Professionals report concern might be less than originally thought

21. Depo-Provera Side Effects • Reduced sexual appetite • Hot flashes • Hair loss • May reduce risk for ovarian, endometrial cancers • Other, rare side effects: chest pain, pulmonary embolus, tachycardia, fever, breast lumps, anemia, fainting, vaginal cysts, asthma (rxlist.com)

22. Depo-Provera: Side Effects • Side effects may continue until Depo-Provera is out of system, up to six months • Some women experience no reversibility problems; others take 6-18 months to return to normal

23. Depo-subQ Provera 104 • Subcutaneous, rather than deep muscle, injection • Thigh or abdomen • 31% lower dose of progestin (Dawn Stacey, about.com) • Similar side effects • Since newer product, less information known

24. Contraceptive Pills • “Combination” = estrogen & progestin • Minipill = progestin only • Beyaz, Femcon Fe

25. Contraceptive Pills • Seasonique & Natazia

26. Sterilization

27. Sterilization: Vasectomy • Vasectomy blocks sperm from traveling through the vas deferens, preventing sperm from mixing into semen • No glands or organs are removed • Effectiveness: 99%+ • Considered irreversible

28. Sterilization: Vasectomy • Vas deferens must be isolated • Similar to tubal ligation, the vas deferens can be cut and tied, clamped, cauterized, no scalpel technique • Another form of contraception must be used for a few months

29. Sterilization: Vasectomy • Cost: $350-1000 (plannedparenthood.org) • Side effects • Bruising • Sensitivity/pain for up to a few weeks past the procedure • Sperm leaking from tubes may lead to small lump (usually clears up on its own) • Antibodies to sperm may develop, reducing chances of fertility in a reversal

30. Vasectomy Complications • Rare • Usually associated with infection (fever, pus/blood from incision site, swelling, pain) • Ends of tubes may grow back together (very rare) • Decreased sexual desire (4 out of 1000 cases per Planned Parenthood) - no apparent physical cause

31. Sterilization: Vasectomy • Animation (BUPA Health via YouTube, 2:36) • Open-ended (no scalpel) vasectomy (medicalvideos.us) • Video (vasectomymedical.com)

32. Sterilization: Tubal Ligation • Surgical technique • Close fallopian tubes, preventing egg from traveling to uterus, preventing sperm from reaching egg • Neither organs nor glands are removed • Effectiveness: 99%+ • Considered irreversible

33. Sterilization: Tubal Ligation • Tubal sterilization: • Tubes can be tied and cut (Pomeroy technique) • Tubes can be cauterized • Tubes can be clipped, clamped • These incision methods often performed after childbirth/abortion • Animation (SMART imagebase)

34. Sterilization: Tubal Ligation • Cost: $1000-3000 • Side effects: thought by many to be rare; hormonal imbalance may lead to increased menstrual bleeding, cramping; adhesions • Complications: infection, internal bleeding, ectopic pregnancy • Before/after photos (private Flickr account)

35. Sterilization: Implants • Non-incision method • No general anesthesia • Under an hour • Coils inserted into fallopian tubes • In following months, coils and tissue grow together, forming barrier to prevent sperm from reaching egg

36. Sterilization: Implants • Side effects: expulsion of coil inserts, risk for ectopic pregnancy, cramping, menstrual changes, nausea/vomiting • Demo (Essure) • Late November: reports of problems coming to a head: headaches, pelvic pain, chronic fatigue, coils moving to other parts of body and hurting tissue, others • “Pre-market approval” = exempt from lawsuits

37. Long-Term Contraception & Sterilization: Project Prevention • Societal aid or eugenics? • FOX News program (1:30 minutes) • ABC News program (2:19 minutes)

38. Fertility Awareness Methods

39. Temperature Method • Females track temperature every morning • Look for slight drop in temperature occurring immediately before ovulation • At ovulation, temperature increases • Temperature changes are small • Look for trends, expect daily fluctuations • Image source: Public domain, Wikimedia Commons

40. Temperature Method • Use basal thermometer • Smaller scale (1/10 degree) • Chart temperature for at least three months before relying on method • Safe sex time begins 72 hours after temperature has risen, remains until temperature begins to drop • Source: Dr. Sacha Elliott, ND

41. Temperature Method • Day 10: 98.5 Day 17: 98.8 • Day 11: 98.4 Day 18: 99.0 • Day 12: 98.4 Day 19: 98.7 • Day 13: 98.1 Day 20: 98.7 • Day 14: 97.9 Day 21: 98.8 • Day 15: 98.0 Day 22: 98.6 • Day 16: 97.5 Day 23: 98.5

42. Cervical Mucus Method • Tracking the variation in mucus consistency throughout cycle • Cervical mucus begins a few days after menstruation • As mucus production increases, it’s yellow or white in color & cloudy, sticky • Will become wet, clear • Clear, slippery mucus = most fertile • Mucus production decreases, cloudy & sticky

43. Cervical Mucus Method • Tracking Your Cervical Mucus, Babycenter.com • “Safe days” = begin after slippery mucus decreases, continue into cloudy & tacky, and especially dry days • Short cycles = mucus may be hidden in menstrual flow

44. Calendar Method • Predicting “safe” and “unsafe” days based on length of monthly cycles • Can use traditional calendar, software, phone app, web tools

45. Calendar Method • Count length of menstrual cycle • Day #1 = first day of menses • Last day = day before menses returns • Eight cycles are recommended before relying on this method (Planned Parenthood) • First fertile day = shortest cycle minus 18 • Last fertile day = longest cycle minus 11

46. Calendar Method • Cycle 1: 24 Cycle 2: 27 • Cycle 3: 25 Cycle 4: 28 • Cycle 5: 25 Cycle 6: 27 • Cycle 7: 29 Cycle 8: 25 • Shortest day: 24 • Longest day: 29 • Unsafe days: #6-18

47. Calendar Method • Online calendar method tool - virtualmedicalcentre.com • Irregular period cycles = reduced effectiveness • Calendar method = requires another method for most to experience adequate effectiveness

48. Contraception in the Future: Nestorone • Estrogen and progestin • Gel • Spray • Acrux Announcement, February 2009 • Figure 2: Estrogen content in Nestorone, OrthoEvra, NuvaRing, combination pills • 2012: Combination of nestorone and testosterone reduced sperm count in UCLA study

49. Contraception: The Future • Male hormonal contraceptive: monthly testosterone injection • 5/ 2009: China clinical trials • 1 in 100 fathered a child • Reversible six months after stopping injections • 1/3 of 1000 participants did not complete; no reason provided • Few side effects reported (acne, weight gain), but more research needed • Contraceptive methods may work better in Asian men vs European men • Photo from BBC

50. Contraception: The Future • RISUG • Reversible Inhibition of Sperm Under Guidance • Contraceptive method for men • Clinical trials in India • Injection into vas deferens of male (video, wired.com, :34) • RISUG disrupts membranes of sperm so they cannot fertilize • One injection to last 10 years • Reversibility not well tested, though reports on primates appear positive (requires another injection) • Marketing challenges