8th Edition APGO Objectives for Medical Students Contraception & Sterilization
Rationale • An understanding of the medical and personal issues involved in decisions regarding contraceptive methods is necessary to adequately advise patients requesting contraception.
Objectives The student will be able to explain: • Physiologic and pharmacologic basis of action • Effectiveness • Benefits and risks • Financial considerations of the various methods of contraception
Contraception in the United States • 64% of women ages 15-44 use some form of contraception • Contraceptive Methods (percentage of users for each method) • Sterilization • Female (27%) • Male (12%) • Oral Contraceptive Pills (OCPs) (27%) • Condoms (20%) • Intrauterine Device (1%) • Depo Provera Injections (3%) • Other (10%)
Contraception in the United States • Mechanism - No exposure to sperm during fertile period • Failure - 19% during first year of use • Advantages - low cost, managed by patient herself • Disadvantages • High failure rate in unmotivated • Variability between menstrual cycles
Periodic Abstinence • Natural Family Planning (2.3%)
Barrier Methods • Prevent sperm and ova from mating • Condoms • Protect against STDs • Male • Failure rates • Perfect - 3% • Typical - 16% • Cost $1-$10 depending on brand/type
Barrier Methods • Condoms • Female • Failure rates • Perfect - 5% • Typical - 21% • Cost $2-$3 each; use with each intercourse act
Barrier Methods • Diaphragm • Used in conjunction with spermicide • Failure rates • Perfect - 6% • Typical - 18% • Advantage - low cost $30-$40 • Disadvantage - increased rate of UTI, needs to be fitted by MD act
Barrier Methods • Cervical Cap • Failure rates • Perfect use /Typical use • Nulliparous 9% / 20% • Multiparous 26% / 40% • Disadvantages • Must have normal PAP smear • Must be fitted initially by MD • High failure rate in multiparous patient • Cost approximately $30, plus office visit
Oral Contraceptive Pills • Mechanism of action • Blocks mid-cycle gonadotropin surge • Thickens cervical mucus • Alters uterine and tubal motility • Creates hostile endometrium (impairs blastocyst survival)
Oral Contraceptive Pills • Contraindications • Deep vein thrombosis (DVT) or pulmonary embolus(PE) • Current or in past • Cerebrovascular disease • Uncontrolled hypertension or coronary artery disease • Migraine with focal neurological symptoms • Congestive heart failure • Age > 35 and smoker • Estrogen - dependent neoplasm • Undiagnosed vaginal bleeding • Pregnancy • Active liver disease
Oral Contraceptive Pills • Failure • Perfect use <1% • Typical use 6%
Oral Contraceptive Pills • Advantages • Decreased incidence of endometrial cancer • Decreased incidence of ovarian cancer • Less dysmenorrhea • Less PMS/PMDD • Decreased amount of menstrual flow • Decreased incidence of functional ovarian cysts • Decrease in benign breast disease • Decreased incidence of pelvic inflammatory disease (PID) • Decrease in acne
Oral Contraceptive Pills • Disadvantages • $30 per month • ? Increase in breast cancer if used >4 yearsunder age 25 • ? Increase in cervical cancer with prolonged use
Progestins (long acting) • Mechanism of action • Inhibit ovulation • Thickens cervical mucus • Thins endometrium
Progestins: Types Depo-Provera (Injection every 12-14 weeks) • Advantages • Reversible • Good safety profile • Effective - 0.3% failure rate • Disadvantages • Irregular bleeding • Amenorrhea • Breast tenderness • Weight gain (up to 5 lbs per year) • Depression • Possible slow return to fertility • Cost $40 every 3 months
Progestins: Types Depo-Provera (Injection every 12-14 weeks) • Norplant • 6 rods in arm • Not currently available in United States • Implanon • Single rod in arm • FDA approved, but not used in U.S. yet • Usually improves within 3 cycles • Only during first 21 days after insertion • Increased risk of septic abortion if IUD not removed • Higher percentage of pregnancies are ectopics
Emergency contraception • Given within 72 hours of unprotected intercourse • 90% effective • Side effects • Nausea and vomiting • Breast tenderness • Headache • Dizziness • Examples • Ovral - 2 pills q 12 hours x 2 doses • IUD inserted within 5 days of unprotected intercourse • 0.1% failure rate
Intrauterine Device • Mechanism of action • Inhibit sperm motility • Hostile uterine environment for sperm • May inhibit ovulation (Mirena)
Intrauterine Device • Contraindications to insertion • Pregnancy • Distortion of the uterine cavity • Acute pelvic inflammatory disease • Other uterine infections • Uterine or cervical cancer • Unresolved abnormal PAP smear • Untreated acute cervicitis or vaginitis • Wilson’s disease or allergy to copper (ParaGard) • Genital actinomycosis • Multiple sexual partners or partner with multiple sexual partners • Immunosuppression (AIDS, leukemia, IV drug use) • Previous IUD still in place
Intrauterine Device • Failure rate <1% • Advantages • Duration 10 years (ParaGard), or 5 years (Mirena) • Low maintenance • Low cost per year of use (approximately $300-$500 initial cost) • Decreased menstrual flow (Mirena)
Intrauterine Device • Disadvantages • Increased menstrual flow (ParaGard) • Increased menstrual cramping • Usually improves within 3 cycles • Does not protect against STDs • Increased risk of infection • Only during first 21 days after insertion • Requires office procedure for insertion/removal
Intrauterine Device • Special consideration • Pregnancy with an IUD in place • Increased risk of septic abortion if IUD not removed • Higher percentage of pregnancies are ectopics
Rationale In the process of deciding whether to have a sterilization procedure, men and women often seek the advice of their physicians. Providing accurate information will allow patients to make an informed decision regarding this elective surgery. Sterilization is the most common form of contraception used by married couples
Objectives The student will be able to list: • Methods of male and female surgical sterilization • Risks and benefits of procedures • Factors needed to help the patient make informed decisions, including: • Potential surgical complications • Failure rates • Reversibility • Financial considerations
Female Sterilization • Failure rate - 2-3/100 (over 10 years) • Fatality rate - 5/100,000
Female Sterilization - Types Tubal ligation and/or resection • Methods • Laparoscopy • Minilaparotomy • Colpotomy
Female Sterilization - Types Tubal ligation and/or resection • Advantages • Immediately effective • Very effective and permanent • Can be done on ambulatory basis • Disadvantages • Anesthesia risks • Potential for perforation of organs • Potential for emergency hospitalization • Potential for bleeding • Potential for infection
Female Sterilization - Types Tubal ligation and/or resection • Tubal ligation types • Modified Pomeroy - knuckle of tube tied and then resected • Parkland - bilateral mid segmental salpingectomy • Madlener - crush and ligate midsection of tube (only of historic value - high failure rate) • Irving - ligate tube and bury proximal stump in the uterine myometrium • Uchida - removal of isthmic portion of tube and burying proximal stump in mesosalpinx
Female Sterilization - Types Tubal occlusion - simple occlusion using silasticrings or tubal clips • Silastic rings (Yoon) - place in isthmic portion of tube • Tubal clip (Hulka or Filshie) - place in isthmic portion of tube • Advantage - simple, safe, minimal amount of tubal destruction
Female Sterilization - Types Tubal electro surgery - bipolar • Simple, effective • Done via laparoscopy
Female Sterilization • Possible complications • General anesthesia • Intraoperative injuries • From trocar • Mesosalpingeal tears • Infection • Ectopic pregnancy • Failed sterilization procedures account for less than 2% of all ectopic pregnancies
Male Sterilization - vasectomy • 500,000 performed annually • Transection of vas deferens • Not sterile until two sperm-free ejaculates, 30 days apart • Advantages • Local anesthetic • Office procedure • Disadvantages • 5% hematoma • Sperm granulomas • Epididymitis • 10% request reversal with a 40% success rate • Failure rates - up to 6%
References - Contraception • Speroff L. Oral contraceptives and venous thromboembolism. International Journal of Gynecology and Obstetrics. 54(1):445-50, Jul. 1996. • Piegsa K, Guillebaud J. Oral contraceptives and the risk of DVT. Practitioner. 240(1566):544-51, Sep. 1996. • Suissa S, Blais L. First-time use of newer oral contraceptives and the risk of venous thromboembolism. Contraception. 56(3):141-6, Sep. 1997.
References - Sterilization • Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Turssell J. “The risk of after tubal sterilization: findings from the U.S. collaborative review of sterilization”. American Journal of Obstetrics and Gynecology, April 1996, 174, No. 4: 1161-1170. • Penfield JA. The Filshie Clip for female sterilization: a review of world experience. American Journal of Obstetrics and Gynecology, March 2000, 182, No. 3: 485-489. • Moore TR, Reiter RC, Rebar RW, Baker V. eds., Gynecology and Obstetrics: A Longitudinal Approach. New York: Churchill Livingstone, 1993.
Clinical Case Contraception & Sterilization
Patient presentation The patient is a 35-year-old G5P4 black woman with BMI > 30 who presents with complaints of severe right lower extremity pain. She reports she was in her usual state of health until about 5 days ago when she had onset of pain in her right lower extremity. The pain has progressively worsened especially in her calf over the past five days. She also has swelling, warmth and redness along her right lower extremity from the foot to mid-thigh. She reports no headaches, dizziness, chest pain, shortness of breath, cough, or dyspnea.
Patient presentation Ob-Gyn history • Spontaneous vaginal delivery times 4 • Elective abortion • Started OCP (Ortho Novum 7-7-7) about 1 year ago • LMP 1 year ago • Negative Pap smear & STD screen Past medical history • Varicose veins • Pneumonia at the age 12
Patient presentation Past surgical history • Cholecystectomy at age 30 • Tonsillectomy at age 13 Social history • H/o tobacco use times ½-pack per day for 10 years; quit 1 year ago • No ETOH; no IVDA • Works as a secretary for a paper company Allergy and medication • None Family History • No cancers, DM, CAD, CVA, or HTN, positive for DVT in her mother
Patient presentation Physical Exam • General: Obese black female in mild distress from leg pain. • VS BP 130/80, RR18, P 86 and regular; wt: 243 • HEENT: PERRLA, NC, NT • Chest: clear to auscultation and percussion • Cardiovascular: Normal rate and rhythm, no murmurs • Breasts: No masses, adenopathy or skin changes • Abdomen: No hepatosplenomegaly, non-tender, obese • Pelvic: External genitalia: Normal • Vagina: Moist, pink, no discharge • Cervix: Parous, no lesions • Biman: Small, anteverted non-tender, no adnexal masses • Extremities: Right lower extremity with posterior calf tenderness, warmth, swelling, and increased pain during dorsiflexion of the foot.
Patient presentation Laboratory or studies • Hbg 10.8 Hct 31.7 vol.% • PT/ PTT 12 sec/ 55 se • Protein S - pending • Protein C - pending • Von Willebrands - pending • Lupus Anticoagulant - pending • A duplex venous ultrasonography of her right lower extremity showed occlusion of the popliteal vein.
Diagnosis Deep vein thrombosis
Treatment • The patient was immediately placed on heparin anticoagulation. She was also started on coumadin and heparin was discontinued once she achieved therapeutic levels of coumadin. She was placed on oral anticoagulation for 6 months, and oral contraceptives were discontinued. She was offered a Paragard IUD vs. a tubal ligation.
Teaching Points • Combination oral contraception is contraindicated in women who have a history of idiopathic venous thromboembolism. In women who have a family history (this patient’s mother had a DVT), the World Health Organization gives a Category 2 rating: A condition where the advantages of using the method generally outweigh the theoretical or proven risks. Although the patient’s family history was not a contraindication to oral contraceptives, her personal history of a DVT now presents a contraindication.
Teaching Points • The rare woman on oral contraception who has a thrombotic episode may have an underlying clotting problem, such as abnormality of Factor V in the clotting cascade (Reference 2.) This patient is likely to have some kind of clotting factor deficiency because her mother has a history of DVT. She should undergo testing for these abnormalities.
Teaching Points • Risk factors for venous disease include (Reference 3.)a. BMI > 30 b. Immobility c. Excessive varicosities d. Family history of DVT in first-degree relative under 45
Teaching Points • A non-hormonal IUD or sterilization are optimal choices of contraception in this patient. • Combined oral contraceptives are very safe in the general population. Good history-taking and adequate counseling may reduce the complications of oral contraceptives (Reference 3.)