PLANNING OF FAMILY

 

Family planning and reproductive health preservation in the practice of the GPFM (general practice/family medicine)

Modern methods of contraception in family doctor’s practice. Classification, mechanism of action and efficiency of contraception

 

One or both members of a couple can use contraception to avoid pregnancy temporarily or sterilization to prevent pregnancy permanently. The contraceptive methods most commonly used in Europe are (in order of popularity) oral steroid pills, condoms, withdrawal, spermicides, intrauterine devices (IUDs). Induced abortion (elective termination of pregnancy) can be used to correct failures of contraception. 

    The advantage and disadvantages of each technique shold be explained so that the woman can choose the one most suitable for herself and for her partner.  Many factors affect rates of contraceptive failure. Adg, level of education, and degree of motivation are inversely related to contraceptive failure rates.

 

Abortion, expulsion of the products of conception before the embryo or fetus is viable. Any interruption of human pregnancy prior to the 22th week is known In Europe as abortion. In USA – to the 20th week. In England – – to the 24 week (!). 

 Beginning of pregnancy controversy

 Controversy over the beginning of pregnancy usually occurs in the context of the abortion debate. Depending on where pregnancy is considered to begin, some methods of birth control or infertility treatment might be considered abortifacient. The controversy is not primarily a scientific issue since knowledge of human reproduction and development has become very refined, but rather is primarily a linguistic and definitional question. The issue may also have social, medical, political and legal ramifications if one equates the “beginning of pregnancy” with the “beginning of an individual human being’s life”.

Traditionally, doctors have measured pregnancy from a number of convenient points, including the day of last menstruation,ovulation, fertilization, implantation and chemical detection. This has led to some confusion about the precise length of human pregnancy, as each measuring point yields a different figure.

    At its 2004 Annual Meeting, The American Medical Association passed a resolution in favor of making “Plan B” emergency contraception available over-the-counter, and one of the claims in the resolution was that hormonal contraception that may affect implantation “cannot terminate an established pregnancy.”

   Similarly, the British Medical Association has defined an “established pregnancy” as beginning at implantation. The legal definition in the United Kingdom is not clear. Other definitions exist. The American Heritage Stedman’s Medical Dictionary defines “pregnancy” as “from conception until birth.” Definitions like this may add to a lay person’s confusion, as “conception” in a medical context may be defined as implantation but in lay terms may mean either fertilization or implantation. Whether conception refers to fertilization or implantation would seemingly even impact “established pregnancies” such as an ectopic pregnancy. If conception is defined as at implantation, ectopic pregnancies could not be called pregnancies. However, some medical professionals who oppose birth control, including prominent member of Focus on the Family Walter Larimore, have argued that the medical definition of conception should include fertilization.

    Finally, the standard historical method of counting the duration of pregnancy begins from the last menstruation and this remains common with doctors, hospitals, and medical companies. This system is convenient because it is easy to determine when the last menstrual period was, while both fertilization and implantation occur out of sight. An interesting consequence is that the dating of pregnancy measured this way begins two weeks before ovulation.

 Legal implications

In August 2008 the U.S. Department of Health and Human Services proposed a regulation to protect certain actions of health workers: refusal to provide patient services that the health workers believe to be abortifacient. The ban on discrimination against these employees would apply to all organizations that receive grant money from HHS. A draft version leaked in July proposed that the U.S. federal government define abortion as including “termination of [human] life… before… implantation.” The official proposal dropped the definition of abortion, instead leaving it to the objecting individual to define abortion for him- or herself. Groups on both sides of the controversy believe the ban is intended to allow health workers to refuse to dispense IUDs and hormonal contraceptives, including emergency contraception. It has drawn widespread criticism from major medical and health groups.

 History

 In the past, pregnancy has been defined in terms of conception. For example, Webster’s Dictionary defined “pregnant” (or “pregnancy”) as “having conceived” (or “the state of a female who has conceived”), in its 1828 and 1913 editions. However, in the absence of an accurate understanding of human development, early notions about the timing and process of conception were often vague.

Both the 1828 and 1913 editions of Webster’s Dictionary said that to “conceive” meant “to receive into the womb and … begin the formation of the embryo.” However most references say that it was only in 1875 that Oskar Hertwig discovered that fertilization includes the penetration of a spermatozoon into an ovum. Thus, the term “conception” was in use long before the details of fertilization were discovered. By 1966, a more precise meaning of the word “conception” could be found in common-use dictionaries: the formation of a viable zygote.

 In 1959, Dr. Bent Boving suggested that the word “conception” should be associated with the process of implantation instead of fertilization. Some thought was given to possible societal consequences, as evidenced by Boving’s statement that “the social advantage of being considered to prevent conception rather than to destroy an established pregnancy could depend on something so simple as a prudent habit of speech.” In 1965, the American College of Obstetricians and Gynecologists (ACOG) adopted Boving’s definition: “conception is the implantation of a fertilized ovum.”

The 1965 ACOG definition was imprecise because, by the time it implants, the zygote is called a blastocyst, so it was clarified in 1972 to “Conception is the implantation of the blastocyst.” Some dictionaries continue to use the definition of conception as the formation of a viable zygote.

Birth control methods usually prevent fertilization. This cannot be seen as abortifacient because, by any of the above definitions, pregnancy has not started. However, some methods might have a secondary effect of preventing implantation, thus allowing thezygote to die. Those who define pregnancy from fertilization subsequently may conclude that the agents should be consideredabortifacients.

Speculation about post-fertilization mechanisms is widespread, even appearing on patient information inserts for hormonal contraception, but there is no clinical support. One small study, using fourteen women, might be considered as providing evidence of such an effect for IUDs and a study of the combined oral contraceptive pill has been proposed.

Possibly affected methods

• Hormonal contraception, including emergency contraception, are known to be effective at preventing ovulation. Some scientists believe hormonal methods may have a secondary effect of interfering with implantation of embryos.

• Intrauterine devices (IUDs) have been proven to have strong spermicidal and ovicidal effects; the current medical consensus is that this is the only way in which they work. Still, a few physicians have suggested they may have a secondary effect of interfering with the development of pre-implanted embryos; this secondary effect is considered more plausible when the IUD is used as emergency contraception.

• The lactational amenorrhea method works primarily by preventing ovulation, but is also known to cause luteal phase defect (LPD). LPD is believed to interfere with the implantation of embryos.

• Natural Family Planning (NFP) methods are intended to prevent fertilization through avoiding intercourse during fertile periods.

    Luc Bovens argues that, under an assumption that the age of gametes has an effect on embryo viability, errors in NFP method result in the occurrence of lower-viability embryos. This is intended to be an ethical thought experiment; Bovens states that his assumption “is not backed up by empirical evidence, but does have a certain plausibility.” His argument is controversial. The age of gametes at the time of fertilization has been shown to have no effect on miscarriage rates in most cases, but is a significant risk factor where there is history of miscarriage. Age of gametes at the time of fertilization has been shown to have no effect on low birth weight or preterm delivery.

A related issue that comes up in this debate is how often fertilization leads to an established, viable pregnancy. Current research suggests that fertilized embryos naturally fail to implant some 30% to 70% of the time. Of those that do implant, about 25% suffer early pregnancy loss by the sixth week LMP (after the woman’s Last Menstrual Period), and an additional 7% miscarry or are stillborn. As a result, even without the use of birth control, between 50% and 70% of zygotes never result in established pregnancies, much less birth.

 Ethics of preventing implantation 

 The intention of a woman to prevent pregnancy is an important factor in whether or not the act of contraception is seen as abortive by some pro-life groups. Hormonal contraceptives have a possible effect of preventing implantation of a blastocyst, as discussed previously. Use of these drugs with the intention of preventing pregnancy is seen by some pro-life groups as immoral. This is because of the possibility of causing the end of a new human life.

   However, hormonal contraception can also be used as a treatment for various medical conditions. When implantation prevention is unintentionally caused as a side effect of medical treatment, such pro-life groups do not consider the practice to be immoral, citing the bioethical principle of double effect. Likewise, when a hormonal contraceptive is used with the intention of preventing fertilisation, the intended reduction in implantation failures, miscarriages and deaths from childbearing may outweigh the possibility that the method might cause some implantation failures.

    A related application of the principle of double effect is breastfeeding. Breastfeeding greatly suppresses ovulation, but eventually an ovum is released. Luteal phase defect, caused by breastfeeding, makes the uterine lining hostile to implantation and as such may prevent implantation after fertilization. Some pro-choice groups have expressed concern that the movement to recognizehormonal contraceptives as abortifacient will also cause breastfeeding to be considered an abortion method.

    Detectable pregnancy

    A protein called early pregnancy factor (EPF) is detectable in a woman’s blood within 48 hours of ovulation if fertilization has occurred. However, testing for EPF is time consuming and expensive; most early pregnancy tests detect human chorionic gonadotropin (hCG), a hormone that is not secreted until after implantation. Defining pregnancy as beginning at implantation thus makes pregnancy a condition that can be easily tested for.

   The term spontaneous abortion, or miscarriage, is used to signify delivery of a nonviable embryo or fetus due to fetal or maternal factors, as opposed to purposely induced abortion. Therapeutic abortion is an induced abortion performed to preserve the health or life of the mother.

 Spontaneous Abortion (Miscarriage)

 Early spontaneous abortion (the most prevalent) is usually due to fetal malformations or chromosomal abnormalities. Spontaneous abortion during the last two thirds of pregnancy is more likely to be due to maternal factors, for example abnormalities of the cervix or uterus, insufficient progesterone, sexually transmitted diseases  that affect the genital tract, endocrine dysfunction (as in hypothyroidism and diabetes  mellitus), or severe emotional trauma. 

 Immunological reactions, in which maternal antibodies mistake the fetus for foreign tissue, have been implicated in recurrent, or habitual spontaneous abortions. It is estimated that at least 20% of all pregnancies end in miscarriage (estimates range from 15% to 75%). Most occur in the first two weeks after conception, and in many cases the mother is not aware of the pregnancy.

 Inducted Abortion

Abortion can be induced for medical reasons or because of an elective decision to end the pregnancy. Procedures for inducing abortion include vacuum suction (the most common, used in the early stages of pregnancy), dilatation and evacuation (D and E), induction (injection of abortifacients such as prostaglandins into the uterus), and hysterotomy (a surgical procedure similar to acesarean section
, used later in pregnancy, especially when the woman’s life is in danger). The “abortion pill,” the drug RU-486 (mifepristone), was approved by the Food and Drug Administration in the United States in 2000. It is used within the first seven weeks of pregnancy. A second drug is taken two days later to start uterine contractions and complete the abortion. The drugs methotrexate and misoprostol have also been used experimentally to end early pregnancies.

  History of Abortion

Abortion induced by herbs or manipulation was used as a form of birth control in ancient Egypt, Greece, and Rome and probably earlier. In the Middle Ages in Western Europe it was generally accepted in the early months of pregnancy. However, in the 19th cent. opinion about abortion changed. In 1869 the Roman Catholic Church prohibited abortion under any circumstances. In England and in the United States in the 19th cent. stringent antiabortion laws were passed.

  Attitudes toward abortion became more liberal in the 20th cent. By the 1970s, abortion had been legalized in most European countries and Japan; in the United States, under a 1973 Supreme Court ruling (see Roe v. Wade), abortions are permitted during the first six months of pregnancy. Abortion remains a controversial issue in the United States, however, and in 1977 Congress barred the use of Medicaid  funds for abortion except for therapeutic reasons and in certain other specified instances. Several state legislatures passed restrictive abortion laws in hope that the Supreme Court would overturn Roe v. Wade, but in 1992 the court reaffirmed the basic principles of the 1973 decision. Nonetheless a number of states have continued to enact restrictions on abortion or abortion clinics in attempts to end abortions.

 From 1995 to 2000 the U.S. Congress repeatedly passed, but President Bill Clinton vetoed, a bill that would ban a rare late-term method of abortion called by its critics “partial-birth abortion.” Subsequent attempts by many U.S. states to ban this method were contested in the courts, and in 2000 the Supreme Court voided such laws that do not include an exception when the health of the mother is endangered. A federal bill banning the procedure was passed again in 2003 and signed into law by President George W. Bush. The law was quickly challenged in the courts, and a federal judge declared it unconstitutional in 2004 in part because of its lack of a health exception, but the Supreme Court, with two new conservative members appointed by President Bush, upheld the law in 2007. U.S. opponents of abortion have used more militant tactics at times in attempts to disrupt the operations of facilities that perform abortions, and a few extremists have resorted to bombings and assassination. In India, the abortion of female fetuses by couples desiring a male child led (1994) to criminal penalties for prenatal testing when done solely to determine the sex of the fetus; such tests have been banned in parts of China for the same reason.

Gestational age relates to the age of an embryo or fetus (or newborn infant). There is some ambiguity as to how it is defined:

• In embryology, the term “gestational age” is seldom used because it lacks precision. The timing of embryonic development starts with fertilization. In mammals, this proceeds through uterine implantation, until birth.

• In human obstetrics, gestational age is often defined as the time elapsed since 14 days prior to fertilization. This is approximately the duration since the woman’s last menstrual period (LMP) began. There is also a further distinction between the calendar gestational age described here, and the developmental gestational age determined by comparing an embryo or fetus to the average age of others that were at the same stage of development.

Unless the exact date of fertilization is known, counting from LMP has been the common method of computing gestational age. It involves the assumption that fertilization in humans typically occurs a consistent period (14 days) from the onset of the LMP. Although this “LMP method” of calculating gestational age is convenient, other methods are in use or have been proposed.^[3]

Some countries count gestational age from fertilization instead of LMP. This method of counting is also known as fertilization age, embryonic age, fertilizational age or (intrauterine) developmental (IUD) age. This method is more prevalent in descriptions of prenatal development of the embryo or fetus. The LMP gestational age is usually greater by about two weeks. Also, pregnancy often is defined as beginning with implantation, which happens about three weeks after the LMP (see the beginning of pregnancy controversy)

An important part of a problem.

Sexually transmitted disease (STD) or venereal disease, term for infections acquired mainly through sexual contact. Five diseases were traditionally known as venereal diseases: gonorrhea, syphilis, and the less common granuloma inguinale, lymphogranuloma venereum, and chancroid. In the 1960s up to 20 other diseases were recognized as being transmitted by sexual contact, and the term “sexually transmitted disease” came into use. Some of the more common of these are AIDS
, genital herpes (see herpes simplex), chlamydia, and human papillomavirus
. Other diseases or infestations that can be transmitted sexually includegiardiasis
, amebiasis, scabies, pubic “crab” lice (see louse), hepatitis (A, B, and C), group B streptococcal infections (seestreptococcus), cytomegalovirus infection, and the protozoan infection trichomoniasis.

   STDs are generally graver in women, in whom diagnosis is often more difficult and treatment less available than for men; untreated they can lead to infertility or cause miscarriage, premature birth, or infection of the newborn. In some instances two or more infections may be present concurrently. The spread of sexually transmitted AIDS increased dramatically during the 1980s and continued through the 1990s. Other STDs are often seen in tandem with AIDS, partly because open sores that they produce can provide an easy route for the AIDS virus to enter the body. In the 2007 it was estimated that 19 million new cases of STDs were contracted in the United States each year.

  Granuloma inguinale is caused by Calymmatobacterium granulomatis and is common in tropical and subtropical regions. Early lesions appear as painless, red, open sores on the skin of the genital and pelvic regions, succeeded by a spreading ulceration of the tissues. If not treated, the condition becomes chronic and may lead to death through anemia and general debility. Antibiotics such as tetracycline can eliminate the infection.

Lymphogranuloma venereum, also common in tropical and subtropical regions, is caused by a strain of Chlamydia trachomatis, an organism classified as a bacterium but having some viral characteristics. The primary genital lesion is often overlooked. The lymphatic structures about the pelvic and rectal region then become involved; blockage of such structures may cause disfigurement and scarring of external genitals. Fever and headache are other constitutional symptoms. Severe involvement of the rectal mucosa may cause intestinal obstruction or stricture. Tetracycline is the drug of choice, although other antibiotics are effective.

    Chancroid is an acute localized infection caused by a bacterium called Hemophilus ducreyi. It can result in painful ulcerations of the skin, usually in the groin. In women symptoms may be absent or limited to painful urination, defecation, or intercourse. Involvement of the lymph nodes occurs in more than half the cases. Usually the disease is self-limited, but it may cause severe destruction of tissue. Antibiotics have been effective in treatment, but resistant strains are an increasing problem.

In order to reduce ignorance and thereby decrease the risk of venereal infection, the U.S. government just before and after World War II encouraged publicity on the matter, for the taboo long associated with public discussion of these contagious diseases had given rise to serious public-health problems. A nationwide campaign was initiated in 1937 by Thomas Parran, then serving as U.S. surgeon general, to educate the public about the incidence, cause, and cure of venereal diseases. As a result, the number of new cases in the United States steadily declined each year until the 1950s, when a rise was noted, especially among teenagers and young adults. In 1998, concerned by high U.S. rates of such common STDs as human papillomavirus, genital herpes, and chlamydia, as well as local outbreaks of syphilis and gonorrhea, the Centers for Disease Control and Prevention began a new far-reaching campaign to combat STDs.

   Public authorities and private agencies coordinate their efforts to identify and isolate promptly all sources of infection. Worldwide, despite advances in diagnosis and treatment, the incidence of STDs has continued to rise and has reached epidemic proportions in many countries. Among the factors believed responsible for increases are changes in sexual behavior (e.g., the use of oral contraceptives), the emergence of drug-resistant strains, symptomless carriers, a highly mobile population, lack of public education, and the reluctance of patients to seek treatment.

    An important part of a problem. More.

    What is Post-Abortion Stress Syndrome?

   Post-abortion stress syndrome, abbreviated as PAS or PASS, is a form of trauma which can occur in a woman after she has had an abortion. It has also been called post-traumatic abortion syndrome. Many women experience brief feelings of sadness or guilt after having an abortion. Women with PASS experience these feelings for a long period of time. These symptoms also often interrupt their everyday lives and can lead to more severe symptoms. This disorder is often compared to post-traumatic stress disorder (PTSD), a disorder which is ofteoticed in military veterans. Many symptoms of these two disorders are similar.

   The topic of post-abortion stress syndrome brings about great controversy among pro-life and pro-choice groups everywhere. In fact, there is still much debate regarding whether this problem actually exists, as it is not recognized by the American Psychological Association. Some fear this may only be a syndrome invented by pro-life groups in an attempt to hinder further abortions; others claim they themselves have experienced this problem. Still, other groups of people recognize PASS as a problem but believe it is very rare and mention that giving up a child for adoption would seem to be more traumatic than a typical abortion.

Who is susceptible to Post-Abortion Stress Syndrome?

Certain women may be more susceptible to PASS than other women. Women who may be more susceptible to this form of trauma can include:

·        A woman who felt pressured to have an abortion

·        A woman who experienced her abortion after her first trimester passed

·        A woman who did not consider many different choices

·        A woman who has strong religious views

·        A woman who did not have her baby because it would have a birth defect

·        A woman who did not receive counseling after her abortion

·        A woman who has an unstable lifestyle

·        A woman who was not well informed about her abortion

·        A woman who recognizes that a fetus is a human

·        A woman who rushed and did not give her decision much thought

   Symptoms of Post-Abortion Stress Syndrome

Effects of PASS are often very difficult to manage and can involve a variety of risky behaviors. Intensity of these symptoms varies from person to person. Symptoms include:

·        Guilty feelings

·        Poor school and work performance

·        Nightmares

·        Thoughts of suicide

·        Sudden phobias (especially of medical buildings)

·        Poor quality of sleep

·        Self-injury

·        Drug and alcohol abuse requiring the help of a drug rehab facility

·        Irritability

·        Feeling of numbness

·        Relationship complications

·        Constant crying

·        Flashbacks

·        Desire to have a child

·        Anxiety

·        Overprotective of future children

·        Depression

·        Inability to function around babies or pregnant women

·        Panic attacks

·        Inability to make decisions

·        Eating disorder requiring eating disorder treatment

Symptoms of PASS may not occur immediately after one has had an abortion. In many cases, numbness will overcome a woman and the feelings of an abortion will be held back for months or even years. Some women however can live their entire lives and feel perfectly fine after having an abortion. Triggers which may initiate PASS in a woman after having an abortion include seeing another pregnant woman, certain smells or sounds, marriage, or the anniversary date of the abortion.

Women who have had an abortion often feel uncomfortable or ashamed to talk about their experience and thus never seek trauma treatment. These women deserve to find recovery, instead of suffering in loneliness. Trauma treatment centers or depression treatment facilities are excellent places to receive trauma therapy and at last find hope and joy in a renewed life.

 

Post-Abortion Syndrome (PAS) is a type of Post-Traumatic Stress Disorder. It occurs when a woman is unable to work through her emotional responses due to the trauma of an abortion.

Woman are often surprised to find that abortion can be a traumatic experience. Generally, women are not encouraged to share their responses to the abortion. Often it is kept a secret and a woman is left alone with her feelings. The grief a woman may experience after an abortion is seldom recognized and is often repressed or denied. Post-Abortion Syndrome occurs when the grieving process is not completed. Our society is just now beginning to recognize the need to grieve a miscarriage, but because abortion is considered a voluntary act, a women’s grief after an abortion is not understood or supported.

Some women experience PAS symptoms within months of the abortion. For others, the crisis occurs two to five years after the abortion — at the time the normal grieving process would have been completed. Sometimes women don’t experience PAS symptoms for 10, 20, or 30 years because they are unable to deal with the deep emotions caused by the abortion.

What are common symptoms of Post-Abortion Syndrome?

 

§  Anxiety

§  Regret / Guilt

§  Sadness / Sorrow

§  Feelings of loss

§  Repeat abortions

§  Desire for secrecy about abortion

§  Emotional pain

§  Nightmares

§  Anger / Rage

§  Suicidal impulses

§  Self destructive behavior

§  Drug and alcohol abuse

Inability to sustain an intimate relationship

 

How can a woman recover from PAS?

A woman who is experiencing PAS needs to complete the natural grieving
process. This can be done in individual counseling, group therapy, or in a resident
counseling center.

   As established in the last segment, abortion is intrinsically traumatic, although not all will be traumatized by it. But some women will develop a form of post-traumatic stress disorder known as post-abortion stress syndrome, or PAS.

 The existence of PAS is in dispute in the medical community, for what I can only imagine are ideological reasons that have nothing to do with health or care. As discussed previously, even abortion clinic workers are traumatized by what they are doing, and many of them claim to be doing it for benevolent reasons. It is clear then that the perceived benefit of abortion is no defense against being traumatized by it. Many women do not express regret over their abortions because they believe the abortions helped them, and sometimes they even believe the abortions helped the unborn child. We’ve already seen, though, that guilt and regret are absolutely unnecessary in the development of post-traumatic stress disorder. The perpetrator can indeed be traumatized by her own actions because the traumatic response occurs in the brain at a fundamental level that does not consider the belief systems she may have constructed that justify these actions. When she develops post-traumatic stress disorder, she is responding to the perceived threat against her own life that is inherent in the destruction of the life held so intimately in her own body.
    But while guilt is not a factor in the development of PAS, a feeling of helplessness is, according to Dr. Robert C. Scaer, MD, author of The Body Bears the Burden: Trauma Dissociation and Disease (The Haworth Medical Press, 2001). In his words, PTSD “is produced by threat, shock, or injury that occurs in a state of helplessness,” (Scaer, p.xxi). In the animal kingdom, we see three different responses in situations which threaten the survival of the animal: the fight/flight/freeze response. Most of us are familiar with the fight or flight response. The freeze response is less commonly understood, according to Dr. Scaer. When the animal is helpless, unable to flee or defend itself against a threat, nature provides a third mechanism by which it might possibly survive: the animal freezes in an instinctual and unconscious reflex into a state of immobility, created and sustained by the parasympathetic nervous system, a division of the autonomic nervous system.
  Sometimes the predator, faced with prey that is suddenly and entirely immobile as if dead, gives up and the animal survives – “playing possum.” Additionally, in the freeze response, the brain releases endorphins, which we all know as the body’s natural pain killers. Dr. Scaer remarks, “Whether this analgesia has survival value, or is a gift from a greater Being to prevent a painful death is open to debate,” (Scaer, p. 16). Another reason for the animal to be dissociated from the pain might be to keep it from its natural desire to tend to its wounds before it has completely reached safety, just as endorphins work in the flight or fight response to keep the animal from feeling pain that would impede either action.
 Following the freeze response, there is a “discharge” of this autonomic nervous energy, which has been stored while the animal mimicked death. Animals in the wild and in the laboratory have been observed to tremble and perspire when they arouse from the freeze response, and oddly enough, the first movement they make is often a postural representation of what they were doing at the exact moment the freeze response was invoked – their legs will work as though running, for example, if they froze while being pursued, even while they are still lying on the ground. This is indicative of a period of unconsciousness or amnesia.
 Dr. Scaer postulates that the freeze response exists in humans, but not usually to the extent it is seen in the animal kingdom. He describes it as the psychological equivalent of dissociation, in which specific, anxiety-provoking thoughts, emotions, or physical sensations are separated from the rest of the psyche: “…people [suffering trauma]…will frequently relate that they felt as if they were ‘in shock.’ This is often related as a sense of detachment, numbness, and even confusion. Time often seems to stand still. Some patients report that they feel as if they are detached and removed from their body, occasionally reporting the events of the trauma as if they were seeing them as a third person…many of the posttraumatic symptoms that occur often for years after the unresolved trauma are characteristic of dissociation, or recurrence of the symptoms of freezing,”.
 Humans also don’t seem to have a period of discharge of autonomic nervous system energy after trauma, either, which leads Dr. Scaer to speculate that “the self-perpetuated circuitry involved in kindling is remarkably compatible with absence of discharge…”. “Kindling” results from the build-up of nervous energy that is not dissipated. Dr. Scaer believes that without the dissipation of this autonomic nervous system energy, “the ‘survival brain’ may continue to perceive that the threat continues to exist, and is unable to relegate it to memory as a past experience,” . In other words, post-traumatic stress disorder is physiologically expressed by autonomic nervous system dysfunction.
 Kindling refers to the spontaneous combustion of materials reaching a certain critical temperature. Ieurological terms, kindling refers to the process by which electrical impulses can add up and trigger spontaneous responses. The PTSD nervous system smolders with undischarged energy that bursts into full flame, and the resulting neuropsychological symptoms include flashbacks, intrusive memories, cue-related memories, nightmares, anxiety, panic attacks, phobias of events and places reminiscent of the trauma, memory and situation-induced arousal, mood changes, irritability, stimulus sensitivity (to light and sound, for example), exaggerated startle response, and insomnia. Furthermore, because the autonomic nervous system is involved, there are “often dramatic physical symptoms, including bowel disorders, myofasical pain, and cognitive impairment….We therefore seem to be dealing with a syndrome affecting all aspects of a person’s being, including body, mind, and spirit,”.

This leads Dr. Scaer (and others) to the conclusion that “many of those chronic diseases that seem to be the most common,” and the most difficult to treat, “may well have their roots in the insidious systemic effects of traumatization,”.

 He continues, “in fact, I believe that the most common complaint in current medical practice, that of persistent and unexplained chronic pain, has its roots in the persistent changes in brain circuitry associated with unresolved traumatization, and the continued tendency for dissociation to occur in the face of stress or threat,” (ibid). He describes the disorders resulting from post-traumatic stress disorder as psychophysiological, and they include fibroymalgia, chronic fatigue syndrome, reflex sympathetic dystrophy, and somatization disorders that drive people to doctor after doctor, seeking a diagnosis for that which apparently cannot be explained. Dr. Scaer is very sympathetic to these patients, adding that they suffer the burden of being retraumatized and devalued by a medical community that will deny the physical validity of their very real pain.
   The physical complaints associated with post-traumatic stress disorder include headaches, gastrointestinal complaints, immune system problems, dizziness, chest pain and other pains throughout the body. NIMH explains that “Often, doctors treat the symptoms without being aware that they stem from PTSD. NIMH, through its education program, is encouraging primary care providers to ask patients about experiences with violence, recent losses, and traumatic events, especially if symptoms keep recurring.”
   One of the most mysterious of the psychophysiological disorders is fibromyalgia. More than 90% of those diagnosed with fibro are women of reproductive age. Researchers have already noted that large numbers of those women diagnosed with fibromyalgia have some kind of trauma in their histories – most often, it is childhood physical and/or sexual abuse. The physical symptoms of fibromyalgia include: headaches, fatigue, pain, vertigo (dizziness), chest pain, irritable bowel syndrome, low-grade fever and flu-like feelings. It seems likely that Dr. Scaer and the National Institutes of Mental Health are correct in speculating that fibromyalgia and its cousins may actually be undiagnosed post-traumatic stress disorder, undiagnosed in my opinion because physicians and researchers aren’t able to identify a source of trauma – but then, they aren’t looking for abortion in our medical histories. For the most part, it seems the medical community is standing around scratching its collective head while women get sicker and sicker with illnesses they can’t quite diagnose or understand.

As we can see from Dr. Scaer’s model of the freeze response, helplessness is a primary factor in determining whether a traumatic event will be traumatizing. According to the Elliott Institute’s report,Forced Abortion in America, eight in ten women who had abortions report they would have chosen to give birth instead if they had received support and encouragement from friends and family. The woman who aborts her child because she feels she has to, because she is financially, socially, or otherwise isolated and without help submits to a procedure that results in violent death, and is primed to develop post-traumatic stress disorder as a result.

Not all women who have abortions will develop PAS, as I’ve mentioned before, but that shouldn’t ease our minds. Most people who suffer from post-traumatic stress disorder have multiple traumas in their histories which did not at that time trigger symptoms of PTSD, but which weakened them against future traumas, making them more susceptible to develop the disorder each time. Also, the symptoms of PTSD appear on a continuum – some will suffer less than others. Again, each successive traumatic event will be more difficult to handle, and, because of the kindling effect in the nervous system, it actually takes less severe trauma to incur the most severe results as time and stress march on. Occasionally, I have to take a second look at the title of my blogspot – abortion hurts. We have been practicing unrestricted abortion on demand in this nation for thirty years without regard to the consequences, and without medical research that determines whether or not this is really as benign a procedure as we are promised it will be. It’s pretty clear to me, though, that the evidence is already in. Not only is abortion not benign, it is malignant, and it is making us sick.

 

  Synonyms and related keywords: fertility, population growth, reproduction, contraceptive techniques, family planning, spermicidal barriers, spermicidal agents, spermicides, abstinence, coitus interruptus, lactational amenorrhea, condom, rubber, diaphragm, cervical cap, contraceptives, implants, depomedroxyprogesterone acetate, DMPA, intrauterine devices, IUDs, sterilization, vasectomy, emergency contraceptive pills, ECP

 

 

The practice of contraception is as old as human existence. For centuries, humans have relied upon their imagination to avoid pregnancy. Ancient writings noted on Kahun papyrus dating to 1850 BC refer to contraceptive techniques using a vaginal pessary of crocodile dung and fermented dough, which most likely created a hostile environment for sperm. The Kahun papyrus also refers to vaginal plugs of gum, honey, and acacia. Soranus of Ephesus during the early second century in Rome created a highly acidic concoction of fruits, nuts, and wool that was placed at the cervical os to create a spermicidal barrier.

Today, the voluntary control of fertility is of paramount importance to modern society. From a global perspective, countries currently face the crisis of rapid growth of the human population that has begun to threaten human survival. At the present rate, the population of the world will double in 40 years; in several of the more socioeconomically disadvantaged countries, the populations will double in less than 20 years.

 On a smaller scale, effective control of reproduction can be essential to a woman’s ability to achieve her own individual goals as well as contribute to her sense of well-being. A patient’s choice of contraceptive method involves factors such as efficacy, safety, noncontraceptive benefits, cost, and personal considerations. This article discusses the predominant modes of contraception used in the United States, along with the safety, efficacy, advantages, disadvantages, and noncontraceptive benefits of each.

Coitus interruptus

Coitus interruptus involves withdrawal of the entire penis from the vagina before ejaculation. Fertilization is prevented by lack of contact between spermatozoa and the ovum. This method of contraception remains a significant means of fertility control in the developing world.

Efficacy: Effectiveness depends largely on the man’s capability to withdraw prior to ejaculation. The failure rate is estimated to be approximately 4% in the first year of perfect use. In typical use, the rate is approximately 19% during the first year of use.

Advantages: Advantages include immediate availability, requires no devices, no cost, does not involve chemicals, and theoretical reduced risk of transmission of sexually transmitted diseases (STDs).

Disadvantages: A high probability of pregnancy exists with incorrect or inconsistent use.

Lactational amenorrhea

Elevated prolactin levels and a reduction of gonadotropin-releasing hormone from the hypothalamus during lactation suppress ovulation. This leads to a reduction in luteinizing hormone (LH) release and inhibition of follicular maturation. The duration of this suppression varies and is influenced by the frequency and duration of breastfeeding and the length of time since birth. Ovulation usually returns after 6 months despite continuous nursing.

Efficacy: Perfect use failure rate within the first 6 months is 0.5%. Typical use failure rate within the first 6 months is 2%.

Advantages: Involution of the uterus occurs more rapidly. Menses are suppressed. This method can be used immediately after childbirth. This method facilitates postpartum weight loss.

Disadvantages: Return to fertility is uncertain. Frequent breastfeeding may be inconvenient. This method should not be used if the mother is HIV positive.

Natural family planning

Natural family planning is one of the most widely used methods of fertility regulation, particularly for those whose religious or cultural beliefs do not permit devices or drugs for contraception. This method involves periodic abstinence, with couples attempting to avoid intercourse during a woman’s fertile period—around the time of ovulation. Techniques to determine the fertile period include the calendar method, cervical mucus method, or the symptothermal method.

 The calendar method is based on 3 assumptions as follows: (1) A human ovum is capable of fertilization only for about 24 hours after ovulation, (2) spermatozoa can retain their fertilizing ability for only 48 hours after coitus, and (3) ovulation usually occurs 12-16 days before the onset of the subsequent menses. The menses is recorded for 6 cycles to approximate the fertile period. The earliest day of the fertile period is determined by the number of days in the shortest menstrual cycle subtracted by 18. The latest day of the fertile period is calculated by the number of days in the longest cycle subtracted by 11.

With the cervical mucus method, the woman attempts to predict her fertile period by quantifying the cervical mucus with her fingers. Under the influence of estrogen, the mucus increases in quantity and becomes progressively more elastic and copious until a peak day is reached. This is followed by a scant and dry mucus, secondary to the influence of progesterone, which remains until the onset of the next menses. Intercourse is allowed 4 days after the maximal cervical mucus until menstruation.

   The symptothermal method predicts the first day of abstinence by either utilizing the calendar method or the first day mucus is detected, whichever is noted first. The end of the fertile period is predicted by use of basal body temperature. The basal body temperature of a woman is relatively low during the follicular phase and rises in the luteal phase of the menstrual cycle in response so the thermogenic effect of progesterone. The rise in temperature can vary from 0.2-0.5°C. The elevated temperatures begin 1-2 days after ovulation and correspond to the rising level of progesterone. Intercourse can resume 3 days after the temperature rise.

Efficacy: The failure rate in typical use is estimated to be approximately 25%.

Advantages: No adverse effects from hormones occur. This may be the only method acceptable to couples for cultural or religious reasons. Immediate return of fertility occurs with cessation of method.

Disadvantages: This is most suitable for women with regular and predictable cycles. Complete abstinence is necessary during the fertile period unless backup contraception is utilized. This method requires discipline. The method is not effective with improper use. A relatively high failure rate exists. This method does not protect against STDs.

Male condom

The condom consists of a thin sheath placed over the glans and the shaft of the penis that is applied before any vaginal insertion. It is one of the most popular mechanical barriers. Among all of the barrier methods, the condom provides the most effective protection of the genital tract from STDs. Its usage has increased from 13.2-18.9% among all women of reproductive age because of the concern regarding the acquisition of HIV and STDs. It prevents pregnancy by acting as a barrier to the passage of semen into the vagina

Efficacy: The failure rate of condoms in couples that use them consistently and correctly during the first year of use is estimated to be about 3%. However, the true failure rate is estimated to be about 14% during the first year of typical use. This marked difference of failure rates reflects the error of usage. Common errors with condoms usage include failure to use condoms with every act of intercourse and throughout intercourse, improper lubricant use with latex condoms (eg, oil-based lubricants), incorrect placement of the condom on the penis, and poor withdrawal technique.

Advantages: Condoms are readily available and usually are inexpensive. This method involves the male partner in the contraceptive choice. Condoms are effective against both pregnancy and STDs.

Disadvantages: Condoms possibly decrease enjoyment of sex. Some users may have a latex allergy. Condom breakage and slippage decrease effectiveness. Oil-based lubricants may damage the condom.

Female condom

The Reality female condom is a polyurethane sheath intended for 1-time use, similar to the male condom. It contains 2 flexible rings and measures 7.8 cm in diameter and 17 cm long. The ring at the closed end of the sheath serves as an insertion mechanism and internal anchor that is placed inside the vaginal canal. The other ring forms the external patent edge of the device and remains outside of the canal after insertion.

   The female condom prevents pregnancy by acting as a barrier to the passage of semen into the vagina. Simultaneous use of both the female and male condom is not recommended because they may adhere to each other, leading to slippage or displacement of either device.

Efficacy: Efficacy trials are noted to be limited. Initial trials have demonstrated a pregnancy rate of 15% in 6 months. The proportion of women using this method of contraception in the United States is less than 1%.

Advantages: The female condom provides some protection to the labia and the base of the penis during intercourse. The sheath is coated on the inside with a silicone-based lubricant. It does not deteriorate with oil-based lubricants. It can be inserted as long as 8 hours before intercourse.

Disadvantages: The lubricant does not contain spermicide. The device is difficult to place in the vagina. The inner ring may cause discomfort. Some users consider the female condom cumbersome. The female condom may cause urinary tract infection (UTI) if left in vagina for a prolonged period.

Diaphragm

The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina. Diaphragms are manufactured in various diameters. A pelvic examination and measurement of the diagonal length of the vaginal canal determines the correct diaphragm size. It is inserted before intercourse so that the posterior rim fits into the posterior fornix and the anterior rim is placed behind the pubic bone. Spermicidal cream or jelly is applied to the inside of the dome, which then covers the cervix.

 

 

It prevents pregnancy by acting as a barrier to the passage of semen into the cervix. Once in position, the diaphragm provides effective contraception for 6 hours. If a longer interval has elapsed without removal of the diaphragm, a fresh spermicide is added with an applicator. After intercourse, the diaphragm must be left in place for at least 6 hours.

Efficacy: Effectiveness of the diaphragm depends on the age of the user, experience with its use, continuity of use, and the use of spermicide. Typical use failure rate within the first year is estimated to be 20%.

Advantages: The diaphragm does not entail hormonal usage. Contraception is controlled by the woman. The diaphragm may be placed by the woman in anticipation of intercourse.

Disadvantages: Prolonged use during multiple acts of intercourse may increase the risk of UTIs. Usage for longer than 24 hours is not recommended due to the possible risk of toxic shock syndrome. The diaphragm requires professional fitting. Poorly fitted diaphragms may cause vaginal erosions. Diaphragms have a high failure rate. Use of a diaphragm requires brief formal training. The diaphragm may develop odor if not properly cleansed.

Cervical cap

The cervical cap is a cup-shaped latex device that fits over the base of the cervix. A groove along the inner circumference of the rim improves the seal between the inner rim of the cap and the base of the cervix. Spermicide is needed to fill the cap one third full prior to its insertion. It is inserted as long as 8 hours before coitus and can be left in place for as long as 48 hours.

A cervical cap acts as both a mechanical barrier to sperm migration into the cervical canal and as a chemical agent with the use of spermicide.

Efficacy: The effectiveness depends on the parity of women due to the shape of the cervical os. With perfect use in the first year, the nulliparous woman’s failure rate is 9%, as opposed to 20% in the parous woman. With typical use within the first year, the failure rate is 20% in the nulliparous woman and 40% in the parous woman.

Advantages: It provides continuous contraceptive protection for its duration of use regardless of the number of intercourse acts. Additional spermicide, unlike the diaphragm, is not necessary for repeated intercourse. The cervical cap does not involve ongoing use of hormones.

   Disadvantages: Cervical erosion may lead to vaginal spotting. A theoretical risk of toxic shock syndrome exists if the cervical cap is left in place longer than the prescribed period. The cervical cap requires professional fitting and training for use. Severe obesity may make placement difficult. A relatively high failure rate exists. Candidates must have history of normal results on pap smears.

Spermicidal agents

Vaginal spermicides consist of a base combined with either nonoxynol-9 or octoxynol. The actual spermicidal agent consists of a surfactant that destroys the sperm cell membrane. Bases include vaginal foams, suppositories, jellies, films, foaming tablets, and creams. These have to be inserted into the vagina prior to each coital act. Use of spermicidal agents also reduces the risk of infection by both viral and bacterial STDs; however, clinical data on its efficacy on preventing the transmission of HIV are limited. Nonoxynol-9 is toxic to the lactobacilli that are part of the normal vaginal flora. Adverse effects include an increased vaginal colonization with the bacteria Escherichia coli that may predispose to bacteriuria after intercourse.

Spermicides prevent sperm from entering the cervical os by attacking the sperm’s flagella and body, reducing their mobility, and disrupting their fructolytic activity, thereby inhibiting their nourishment.

Efficacy: Perfect use failure rate within the first year is 6%. Typical use failure rate within the first year is 26%.

Advantages: The lubrication provided by spermicides may heighten satisfaction in both partners. Another advantage is the ease of application. Either partner can purchase and apply spermicide because it is easily accessible, available over the counter, and inexpensive. Applying spermicide requires minimal patient education. It augments contraceptive efficacy of the cervical cap and diaphragm. Spermicides produce no systemic adverse effects.

Disadvantages: Spermicides provide minimal protection from STDs. Insertion may be uncomfortable for some couples. Vaginal irritation is possible, and spermicide may cause allergic reaction.                                                               

Implant

The US Food and Drug Administration (FDA) approved the contraceptive use of levonorgestrel implants (Norplant) in 1990. This method consists of 6 silicone rubber rods, each measuring 34 mm long and 2.4 mm in diameter and each containing 36 mg of levonorgestrel. The implant releases approximately 80 mcg of levonorgestrel per 24 hours during the first year of use, achieving effective serum concentrations of 0.4-0.5 ng/mL within the first 24 hours. The rate of release decreases to an average of 30 mcg/d in the latter years of use. Release of the progestational agent by diffusion provides effective contraception for 5 years. Contraceptive protection begins within 24 hours of insertion if inserted during the first week of the menstrual cycle. The rods are inserted subcutaneously, usually in the woman’s upper arm, where they are visible under the skin and can be palpated easily.

The mechanism of action is a combination of suppression of the LH surge, suppression of ovulation, development of viscous and scant cervical mucus to deter sperm penetration, and prevention of endometrial growth and development.

Efficacy: The contraceptive efficacy of the method is equivalent to that of surgical sterilization. Overall, pregnancy rates increase from 0.2% in the first year to 1.1% by the fifth year.

Advantages: The longevity of its effectiveness is an advantage. Its effectiveness is not related to its use in regards to coitus. Exogenous estrogen is absent. Prompt return to the previous state of fertility occurs upon removal. No adverse effect on breast milk production occurs.

Disadvantages: A minor surgical procedure is necessary for incision. Difficulty in removal is a disadvantage. Menstrual irregularities are common along with other adverse effects, including weight gain, headaches, mood changes, hirsutism, galactorrhea, and acne.

Absolute contraindications include active thrombophlebitis or thromboembolic disease, undiagnosed genital bleeding, acute liver disease, benign or malignant liver tumors, known or suspected breast cancer, and history of idiopathic intracranial hypertension. Relative contraindications include heavy cigarette smoking, history of ectopic pregnancy, diabetes mellitus, hypercholesterolemia, severe acne, hypertension, history of cardiovascular disease, severe vascular or migraine headaches, and severe depression.

    Appropriate candidates are women who are postpartum or breastfeeding, women who have difficulty with contraceptive compliance, women in whom pregnancy is contraindicated due to medical condition, and patients with contraindications for use of estrogen.

 The only other FDA approved implant is the 2-rod levonorgestrel system, Norplant II. Each rod is 4.4 cm long and contains a cured homogenous mixture of the drug and a polydimethylsiloxane elastomer covered by silicone tubing. Norplant II is approved for 3 years of use but has been shown to be effective for as long as 5 years. Studies have shown Norplant II to have release rates, pregnancy rates, and side effect profiles similar to Norplant.

Injectable depomedroxyprogesterone acetate

Depomedroxyprogesterone acetate (DMPA) is a suspension of microcrystals of a synthetic progestin that is injected intramuscularly. Pharmacological active levels are achieved within 24 hours after injection, and serum concentrations of 1 ng/mL are maintained for 3 months. During the fifth or sixth month after injection, the levels decrease to 0.2 ng/mL, and they become undetectable by 7-9 months after injection.

    DMPA acts by the inhibition of ovulation with the suppression of follicle-stimulating hormone (FSH) and LH levels and eliminates the LH surge. This results in a relative hypoestrogenic state. Single doses of 150 mg will suppress ovulation in most women for as long as 14 weeks. The contraceptive regimen consists of 1 dose every 3 months.

Efficacy: DMPA is an extremely effective contraceptive option. Neither varying weight nor use of concurrent medications has beeoted to alter efficacy. Within the first year of use, the failure rate is 0.3%.

Advantages: DMPA does not produce the serious adverse effects of estrogen, such as thromboembolism. Diminished anemia occurs. Dysmenorrhea is decreased. Risk of endometrial and ovarian cancer is decreased.

  Disadvantages: Disruption of the menstrual cycle to eventual amenorrhea occurs in 50% of women within the first year. Persistent irregular bleeding can be treated by administering the subsequent dose earlier or by adding a low-dose estrogen temporarily. Because DMPA persists in the body for several months in women who have used it on a long-term basis, it can delay the return to fertility. Approximately 70% of former users desiring pregnancy conceive within 12 months, and 90% of former users conceive within 24 months. Similar to the delay in fertility after discontinuation of DMPA, other adverse effects, such as weight gain, depression, and menstrual irregularities, may continue for as long as 1 year after the last injection. Recent studies in the literature have investigated a possible link between DMPA and bone density loss. Results are conflicting and limited.

Injectable medroxyprogesterone acetate and estradiol combination

One of the newest developments in contraception is a combined injectable contraception (Lunelle). A single injection of medroxyprogesterone acetate and estradiol combination (MPA/EC) contains medroxyprogesterone and estradiol cypionate. It recently received FDA approval in the United States and is marketed as a single-use ampule of an aqueous suspension of the 2 hormones. In contrast to DMPA, it contains estrogen and is administered monthly.

   Its mechanism of action is similar to oral contraceptives (OCs) in that it suppresses ovulation.

Efficacy: The contraceptive efficacy and tolerability of MPA/EC was established in 15,614 women who participated in trials conducted by the World Health Organization (WHO). One-year failure rates of less than 1% have been reported in the WHO clinical trials. In a 60-week US multicenter study of 782 women, 1 year of use did not demonstrate any pregnancies.

Advantages: Unlike DMPA, earliest return of ovulation with multiple monthly injections is approximately 60 days after the last injection. Adequate contraception protection occurs regardless of body weight. Return to fertility is 53% and 83% within 6 months and 8 months, respectively. Regular menses occur, with average cycle of 28 days. Dysmenorrhea and menorrhagia decrease. MPA/EC does not demonstrate clinical changes in lipid metabolism. MPA/EC does not appear to cause procoagulant changes.

Disadvantages: Disadvantages include irregular spotting, weight gain, possible decrease in libido, and mild depression. In contrast to other hormonal contraceptive methods, due to its novelty, epidemiological studies and data in regards to cancer risks are limited. More extensive worldwide use and additional studies may demonstrate the risk, if any, on cancer of the reproductive tract. At this point, a theoretical protection of ovarian and endometrial cancers as demonstrated in oral combination contraceptives exists.

  Progestin-only oral contraceptive

  Progestin-only oral contraceptives, also known as the minipill, are not used widely in the United States. Fewer than 1% of users of oral contraceptives utilize them as their sole method of contraception. Candidates for use include women who are breastfeeding and women with contraindications to estrogen use. Two formulations are available, both of which have lower doses of progestin than combined OCs. One formulation contains 75 mcg of norgestrel. The other has 350 mcg of norethindrone.

 Prevention of contraception involves a combination of mechanisms similar to, but not as efficacious as, combination OCs. Mechanisms of action include the following: suppression of ovulation (not uniformly in all cycles); variable dampening effect on the midcycle peaks of LH and FSH; increase in cervical mucus viscosity by reduction in its volume and alteration of its structure; reduction in the number and size of endometrial glands, leading to an atrophic endometrium not suitable for ovum implantation; and reduction in cilia motility in the fallopian tube, thus slowing the rate of ovum transport.

   Efficacy: Serum progestin levels peak approximately 2 hours after administration. Within 24 hours, rapid distribution and elimination returns the level to baseline. Greater efficacy is achieved with consistent administration. Failure rates with typical use are estimated to be 7% in the first year of use. However, any variation can increase the failure rate.

Advantages: Due to the lack of estrogen, minimal evidence exists that demonstrates the serious complications to which estrogen can contribute (ie, thromboembolism). Noncontraceptive benefits include decreased dysmenorrhea, decreased menstrual blood loss, and decreased premenstrual syndrome (PMS) symptoms. Unlike DMPA, fertility is immediately reestablished after the cessation of Progestin-only oral contraceptives.

   Disadvantages: The most significant disadvantage is the continuous need for compliance with regularity of usage. Users need to be counseled on the need for a backup method of contraception if a pill is missed or taken late. A pill is considered late if ingestion occurs 3 hours after the established time of administration. If a pill is missed, it should be taken as soon as possible, the next pill is to be taken at the scheduled time. Backup contraception should be utilized for the next 48 hours. Adverse effects include nausea, breast tenderness, headache, menstrual irregularities, and amenorrhea.

Combination oral contraceptives

OCs have been marketed in the United States since 1962. The dose of sex steroids has declined significantly in the past 40 years. Prior to 1992, the estrogenic component of OCs consisted of either ethinyl estradiol or mestranol. Today, ethinyl estradiol is used in all preparations containing 35 mcg or less of estrogen in the United States. The progestin component consists of norethindrone, levonorgestrel, norgestrel, norethindrone acetate, or ethynodiol diacetate. Recently, 2 new progestins have been added, norgestimate and desogestrel. The other major new development is the reduction in the dosage of ethinyl estradiol to 20 mcg. The major impetus for this change is to improve the safety and reduce side effects. However, little data exist to indicate whether reduction of the estrogen dose is associated with a decreased risk of serious sequelae. These lower doses are associated with a decrease in the incidence of estrogen-related adverse effects, such as weight gain, breast tenderness, and nausea.

 In the United States today, over 30 OC formulations exist. Monophasic OCs have a constant dose of both estrogen and progestin in each of the hormonally active pills. Phasic combinations can alter either or both hormonal components. Use should be initiated either on the first day of the menses or the first Sunday after menses has begun. The majority of the formulations have 21 hormonally active pills followed by 7 placebo pills. This facilitates consistent daily pill intake.

   If a woman misses 1 or 2 pills, she should take 1 tablet as soon as it is remembered. She then takes 1 tablet twice daily until each of the missed pills has been accounted for. Women who have missed more than 2 consecutive pills should be advised to use a backup method of contraception simultaneous to finishing up the packet of pills until their next menses.

   Prevention of ovulation is considered the dominant mechanism of action. Either estrogen or progesterone alone is capable of inhibiting both FSH and LH sufficiently to prevent ovulation. The combination of the 2 steroids creates a synergistic effect that greatly increases their antigonadotropic and ovulation inhibitory effect. They also alter the consistency of cervical mucous, affect the endometrial lining, and alter tubal transport.

Efficacy: Failure rates are associated with individual compliance. Rates range from 0.1% with perfect use to 5% with typical use.

   Advantages: OCs are used as treatment for menstrual irregularity because menses is more regular and predictable. In the prevention of ovulation, OCs can reduce and sometimes eliminate mittelschmerz. Women with anemia secondary to menorrhagia increase their iron stores. Women can manipulate the cycle to avoid menses during certain events, such as vacations or weekends by extending the number intake days of hormonally active pills or by skipping the placebo pill week. OCs prevent benign conditions, such as benign breast disease, pelvic inflammatory disease (PID), and functional cysts. Functional cysts are reduced by the suppression of stimulation of the ovaries by FSH and LH. Ectopic pregnancies are prevented by the cessation of ovulation.

   OCs are noted to prevent epithelial ovarian and endometrial carcinoma. Studies have noted an approximate 40% reduced risk of malignant and borderline ovarian epithelial cancer. This protection appears to last for at least 15 years following discontinuation of use and increases with duration of use. This protection has not been studied with low-dose OCs and/or in women with genetic ovarian cancer syndromes. Use of OCs is associated with a 50% reduction of risk of endometrial adenocarcinoma. Protection appears to persist for at least 15 years following discontinuation of use.

  Disadvantages: Adverse effects include nausea, breast tenderness, weight gain, breakthrough bleeding, amenorrhea, headaches, depression, anxiety, and decreased libido. OCs do not provide protection from STDs. Daily administration is necessary, and inconsistent use may increase the failure rate. A few months of delay of normal ovulatory cycles after discontinuation of OCs may occur. Women who continue to have amenorrhea after a discontinuation period of 6 months require a full evaluation.

  Metabolic effects and safety

·     Venous thrombosis: The estrogen component of OCs has the capability of activating the blood clotting mechanism. Use of low-estrogen OCs is associated with a lower risk of thromboembolism than in OCs with higher levels of estrogen. Although use of OCs is not associated with a detectable hypercoagulable state for most women, users at a greater risk for thromboembolism include heavy smokers, women with high or abnormal blood lipids, women with severe diabetes with damage to the arteries, women with consistently elevated blood pressures, and women who are obese.

·      Hypertension: OCs have a dose-related effect on blood pressure. With the older high-dose pills, as many as 5% of patients could expect to have blood pressure elevations of 140/90 mm Hg or higher. This elevation is believed to be secondary to an estrogen-induced increase in renin substrate in susceptible individuals. Although today’s low-dose pills have minimal blood pressure effects, maintaining a surveillance of blood pressure is advisable.

·     Atherogenesis and stroke: Although androgens and a few of the progestins actually may increase low-density lipoproteins (LDLs) and decrease high-density lipoproteins (HDLs), past use of OCs does not increase the risk of cardiovascular disease. Limited preliminary data have demonstrated that OC use does not lead to coronary atherosclerosis. In rare cases where myocardial infarcts have been found, the cause has beeoted to be of thrombotic rather than of atherosclerotic etiology. In general, a woman’s habits are more significant than the use of OCs in determining her risk for cardiovascular disease. The patient who is sedentary, overweight, a heavy smoker, hypertensive, diabetic, or has hypercholesterolemia is clearly at risk.

·     Hepatocellular adenoma: These benign liver tumors have been associated with use of OCs. Although these tumors are histologically benign, their danger lies in the risk of rupture of the capsule of the liver, leading to extensive bleeding and, possibly, death. With the current low-dose OC combination, the risk for liver tumors is much lower.

·     Cancer

·    The association of OC use and breast cancer in young women is controversial. The Collaborative Group on Hormonal Factors in Breast Cancer performed the most comprehensive analysis of breast cancer and OC use as reported in 1996. This group evaluated original published epidemiological data from more than 20 countries. The results demonstrated that current OC users, and those who had used OCs within the past 1-4 years, had a slightly increased risk of breast cancer. Although these observations support the possibility of a marginally elevated risk, the group noted that the OC users had more breast examinations and breast imaging than the nonusers. Thus, although the consensus states that OCs can lead to breast cancer, the risk is small and the resulting tumors spread less aggressively than usual. Current thought is that OC use may be a cofactor that can interact with another primary cause to stimulate breast cancer.

·  The relationship between OC use and cervical cancer also is quite controversial. A weak association may exist between OC use and squamous cell cancer of the cervix. Important risk factors include early sexual intercourse and exposure to the human papillomavirus. The overall consensus is that if indeed OC use increases the risk of cervical neoplasia, it is a minimal risk. Thus, women who use OCs should have annual Papanicolaou tests.

Contraindications to use include history of deep vein thrombosis, pulmonary embolism, or congestive heart failure; cerebrovascular disease or coronary artery disease; untreated hypertension; diabetes with vascular complications; estrogen-dependent neoplasia; breast cancer; undiagnosed abnormal vaginal bleeding; known or suspected pregnancy; active liver disease; and age older than 35 years and cigarette smoking.

    Although the intrauterine device (IUD) is a highly effective method of contraception, it is used by less than 2% of American women of reproductive age. The reason for such a small percentage stems from the withdrawal of FDA-approved IUDs in the 1970s. The Dalkon Shield IUD was withdrawn due to the series of litigations related to septic abortion deaths. The manufacturers withdrew their product due to the decision that the cost of defending the litigation suits was deemed too expensive.

 Until as recently as last year, the only 2 IUDs available in the United States were the Copper T380 and the progesterone-releasing form. In December 2000, the FDA approved another form of IUD, the levonorgestrel intrauterine system (LNG IUS, Mirena). Over 2 million women in Europe have used this form of contraception in the past decade with great success.

Description

    The T-shaped progesterone-releasing IUD, which is placed into the uterine cavity, is made of ethylene vinyl acetate copolymer. It contains 38 mg of progesterone and minimal amounts of barium sulfate for greater visibility on x-rays. The vertical limbs are 36 mm long and the horizontal arms are 32 mm wide. It has a pair of dark blue double strings that hangs from the lower limb. Approximately 65 mcg of progesterone a day is released from the progesterone form from a reservoir in its stem. This is a sufficient amount of hormone to last for 400 days; therefore, this IUD must be replaced yearly.

The Copper T380 was introduced in 1988. The T-shaped IUD is made of polyethylene with fine copper wire wrapped around the vertical stem. The string is clear or white and hangs from the lower limb of the IUD. This device consists of 308 mg of copper covering portions of its stem and arms. Contraceptive effectiveness continues for 10 years, after which time it must be replaced.

 

 

The LNG IUS is similar in shape to the Copper T380 in that it also consists of a small T-shaped frame with a reservoir that contains LNG, a progesterone. The IUS releases 20 mcg of LNG per day into the uterine cavity for as long as 5 years. It consists of a polyethylene frame with a cylinder containing a polydimethylsiloxane-levonorgestrel mixture enveloping the vertical arm. The cylinder is coated with a membrane that regulates the release of the hormone. This model also is visible on x-ray.

   An IUD causes cervical mucus to be thicker in consistency, thereby altering sperm migration. Uterotubal fluid and motility changes inhibit sperm migration. IUD also results in endometrial suppression.

Efficacy: The failure rate is 2% with the progesterone form, 0.6% with the Copper T380, and of 0.1 % with the LNG IUS. The percentage of women who continue to use these forms of contraception are high after 1 year of use, 81% and 78% with the progesterone forms and copper T380 respectively.

Advantages: IUDs produce no systemic side effects. Ectopic pregnancies are reduced overall; however, the ratio of extrauterine to intrauterine pregnancy is increased if conception does occur. Decreased menstrual blood loss occurs with progesterone IUD. Decreased dysmenorrhea occurs with progesterone IUD. Twenty percent of women experience amenorrhea with LNG IUS.

Disadvantages: Risk of uterine perforation at time of insertion exists. Increased dysmenorrhea occurs with Copper T380. Increased menstrual blood loss occurs in first few cycles with Copper T380 and LNG IUS. Controversy exists regarding whether IUD increases risk of PID. IUD has none of the potential noncontraceptive benefits of hormonal contraceptives. IUDs may be expelled unnoticed. IUDs do not protect against STDs.

    Contraindications include history of previous PID, abnormal or distorted uterine cavity, undiagnosed genital bleeding, uterine or cervical malignancy, history of ectopic pregnancy, increase susceptibility to infection (leukemia, diabetes, valvular heart disease, AIDS), Wilson disease, known or suspected pregnancy, history of genital actinomyces, and active cervical or endometrial infections.

Sterilization is considered an elective permanent method of contraception. Although both female and male sterilization procedures can be reversed surgically, the surgery is technically more difficult than the original procedure and may not be successful. Success is noted to be greater with tubal reanastomosis than with reanastomosis of the vas deferens in regards to reversal of sterilization.

   Female sterilization

  Tubal ligation or “tying tubes”— A woman can have her fallopian tubes tied (or closed) so that sperm and eggs cannot meet for fertilization. The procedure can be done in a hospital or in an outpatient surgical center. You can go home the same day of the surgery and resume your normal activities within a few days. This method is effective immediately.

 Transcervical Sterilization— A thin tube is used to thread a tiny device into each fallopian tube. It irritates the fallopian tubes and causes scar tissue to grow and permanently plug the tubes. It can take about three months for the scar tissue to grow, so use another form of birth control during this time. Return to your doctor for a test to see if scar tissue has fully blocked your fallopian tubes.

 Approximately 1 million American women are sterilized either by surgery on the fallopian tube or hysterectomy each year. Sterilization can be performed in the postpartum period with a small transverse infraumbilical incision or during the interval period. Sterilization during the interval period can be performed with laparoscopy, laparotomy, or colpotomy. The methods of fallopian tube sterilization include occlusion with Falope rings, clips, bands, segmental destruction with electrocoagulation, or suture ligation with partial salpingectomy. Female sterilization prevents fertilization by interrupting the fallopian tube.

 

   

Efficacy: The United States Collaborative Review of Sterilization has examined the failure rate of female sterilization. Rates vary according to the procedure performed.

The cumulative 10-year failure rate with each method of tubal ligation is as follows: spring clip method is 3.7%, bipolar coagulation is 2.5%, interval partial salpingectomy is 2%, silicone rubber bands is 2%, and postpartum salpingectomy is 0.8%.

   Advantages: Female sterilization does not involve hormones. It is a permanent form of contraception. No data indicate that change in libido, menstrual cycle, or lactation occurs. Female sterilization usually is a same day procedure.

Disadvantages: Female sterilization is a procedure that involves general or regional anesthesia. It is permanent contraception, and patients may regret the decision later. Sterilization does not protect the patient from STDs. Sterilization involves all of the risks of surgery. It creates short-term discomfort.

Vasectomy

·           Male Sterilization–Vasectomy—This operation is done to keep a man’s sperm from going to his penis, so his ejaculate never has any sperm in it that can fertilize an egg. The procedure is done at an outpatient surgical center. The man can go home the same day. Recovery time is less than one week. After the operation, a man visits his doctor for tests to count his sperm and to make sure the sperm count has dropped to zero; this takes about 12 weeks. Another form of birth control should be used until the man’s sperm count has dropped to zero.

Vasectomy involves incision of the scrotal sac, transection of the vas deferens, and occlusion of both severed ends by suture ligation or fulguration. The procedure usually is performed under local anesthesia in an outpatient setting. Complications include hematoma formation and sperm granulomas. Occurrence of spontaneous resolution is rare. After sterilization, remnant sperm remains in the ejaculatory ducts. The man is not considered sterile until he has produced sperm-free ejaculates as documented by semen analysis. This usually requires 15-20 ejaculations. Vasectomy prevents the passage of sperm into seminal fluid by blocking the vas deferens.

    Efficacy: The failure rate is determined to be approximately 0.1%.

    Advantages: Vasectomy involves no hormones, it is permanent, it is an outpatient procedure, it is quick, and risk from the procedure is minimal.

Disadvantages: Patients may regret the decision later. Alternative contraception is required until the ejaculate is deemed sperm-free. Vasectomy does not prevent STDs. Short-term discomfort occurs.

    Emergency postcoital contraception is defined as the use of a drug or device to prevent pregnancy after unprotected sexual intercourse. Unwanted pregnancy is common; worldwide about 50 million pregnancies are terminated each year. In the United States, each year, the widespread use of emergency contraception may have prevented over 1 million abortions and 2 million pregnancies that end in childbirth.

A variety of different methods of emergency contraception has been described. Emergency contraceptives available in the United States include the emergency contraceptive pills (ECP), the Copper T380 IUD, and the minipill emergency contraception method (MECM). Both the Preven kit and the Plan B kit are marketed as emergency contraceptives.

 Candidates for emergency contraception include reproductive-aged women who have had unprotected sexual intercourse within 72 hours of presentation independent of the menstrual cycle. No known absolute contraindications to any of these methods exist because the high-dose of hormones is short lived. However, cases of deep vein thrombosis (DVT) in women using the ECP method have been documented.

Emergency contraceptive pills and the minipill emergency

contraception method

   The ECP mode utilizes 2 OCs, each containing 0.05 mg of ethinyl estradiol and 0.5 mg of norgestrel, ingested 12 hours apart for a total of 4 pills. The first dose should be taken within the first 72 hours after unprotected intercourse; however, studies do demonstrate effectiveness if taken after that period.

    Only the progestin levonorgestrel has been studied for the use in MECM. The treatment schedule is 1 dose of 750 mcg levonorgestrel taken as soon as possible and no later than 48 hours after unprotected intercourse and a second dose taken 12 hours later.

    The mechanism action of either the ECP or MECM is not clearly established. If administered before ovulation, both methods may inhibit follicular development and maturation, resulting in anovulation and deficient luteal function. Treatment following ovulation may affect the endometrium, thus inhibiting implantation. They also may affect tubal transport of the sperm or ova. However, both menses and fertility return with the next cycle.

   Efficacy: Most studies cite an effectiveness rate of 55-94%, with the true effectiveness rate likely to be about 75%. Based on one randomized trial comparing the ECP protocol to the MECM, the MECM seems to be just as effective with far less nausea and emesis (Ho, 1993). Patients must understand that the effective rate of 75% does not translate into a 25% failure rate. Instead, when considering 100 women who have had unprotected sexual intercourse during the middle 2 weeks of their cycle, approximately 8 will become pregnant. Of those 8 who have used ECPs, only 2 will then become pregnant. Despite this significant reduction in the rate of pregnancy, patients must understand that this method of contraception should be used only in emergencies and that they should be encouraged to use other more consistent forms of contraception.

   Several factors complicate the calculation of a failure rate. Factors include dependence on the patient’s history of their last menstrual period and day of exposure, effect of regular and irregular menstrual cycles on the calculation of the estimated time of ovulation, the possibility of the patient being pregnant, and the possibility that more than one unprotected coitus has occurred during that period.

Disadvantages: Adverse effects include nausea and emesis, minor changes in menses, breast tenderness, fatigue, headache, abdominal pain, and dizziness. Ectopic pregnancy is possible if treatment fails.

Copper T380 intrauterine device

The Copper T380 IUD can be inserted as many as 7 days after unprotected sexual intercourse to prevent pregnancy. Insertion of the IUD is significantly more effective than either the ECP or MECP regimen, reducing the risk of pregnancy following unprotected intercourse by more than 99%.

  In 1996, the Institute of Medicine (IOM) produced a report that examined the need for additional contraceptive choices and investigated the climate for development. The report was a follow-up to the 1990 IOM evaluation of obstacles and opportunities for contraceptive development. Their findings noted that the array of contraceptive choices was limited in regards to specific health problems, cultural differences, life cycle changes, and reproductive intentions. The committee also noted that regulatory issues, political pressures, and legal concerns have deterred pharmaceutical manufacturers from investigating new forms of contraception despite the evidence of need and market demand. As a result, the burden of research and development has shifted to small firms and nonprofit organizations that are not as well-equipped to bring new contraceptives to market.

 Although contraceptive development in the United States has slowed in the past few years, research outside of the United States continues at a rapid pace. Many new contraceptive designs are under investigation to provide a greater variety of contraception that have fewer side effects, are safer, and are more efficacious. As a final note to this chapter, a few of the newer methods and forms of contraception soon to be on the market will be discussed.

    Soon to be available in the United States is a contraceptive transdermal patch that releases estrogen and progesterone directly into the skin (Evra). Each patch contains a 1-week supply of hormones. It releases a sustained low daily dose of steroid doses equivalent to the lowest-dose oral contraceptive. Advantages include greater compliance and decreased adverse effects, such as nausea and vomiting, due to avoidance of the first pass effect. However, the patch may cause skin irritation, and, if it is removed unnoticed, such as from showering, it may compromise efficacy.

 One of the more exciting new developments is a hormonal contraceptive method for men. The male birth control pill manipulates steroid hormones to decrease spermatogenesis, as well as testosterone secretion.

  Newer methods of subdermal implants are on the horizon. Implanon is a single-rod implant that is 4 cm long and 2 mm in diameter. It consists of 68 mg of etonogestrel in an ethylene vinyl acetate copolymer core. Etonogestrel is a biologically active metabolite of desogestrel. Desogestrel is significantly more potent than levonorgestrel; a serum concentration of 0.09 ng/mL can inhibit ovulation in most women. Serum concentrations are adequate for contraception coverage for approximately 3 years. In more than 10 different studies utilizing 4000 women-years of use, no pregnancies have been demonstrated.

 The advantages it has as compared to the Norplant system include higher incidence of amenorrhea and oligomenorrhea, decrease in the incidence of frequent and prolonged bleeding, and a decrease in the incidence of side effects such as weight gain, headache, and acne. When the rod is removed, the return to fertility is rapid, with return of ovulation within 3 weeks. Implanon was approved for usage in the United Kingdom in 1999, it still awaits FDA approval in the United States. Understanding of the long-term effects and overall safety data are limited at this point.

   Uniplant is also a single-rod implant system that consists of 55 mg of nomegestrol acetate in a capsule that is 3.5 cm long and 2.4 mm in diameter. Uniplant has been shown to be highly effective for as long as 1 year, with incidence and degree of menstrual irregularities similar to those of Norplant.

 Clinical studies are in progress for a biodegradable implant, Capnor, to eliminate the necessity of implant removal. This is a single 40-mm rod that contains levonorgestrel and maintains contraceptive protection for 1 year.

Biodegradable pellet implants containing norethindrone and cholesterol currently are undergoing investigation. They dissolve within 2 years and release the norethindrone for 12-18 months. Insertion of the pellets has been demonstrated to be simple; however, if the patient wishes for removal several months later, removal has beeoted to be difficult.

 The contraceptive vaginal ring is a new form of contraception that is expected to be on the market in the near future. The actual design of vaginal rings as a mode of contraception was first developed in the 1970s. The first rings studied were homogenous devices with the steroid mixed uniformly through a polysiloxane matrix. The design was abandoned because of a high initial release of drug with rapid decrease of drug release thereafter. The vaginal rings can deliver progesterone or progesterone/estrogen combinations. The combined ring is in the most advanced development phase. It releases both norethindrone acetate and ethinyl estradiol. The hormones are released slowly and absorbed directly by the reproductive organs. Preliminary studies demonstrate efficacy of prevention of pregnancy similar to OCs with fewer side effects. These would be used in the same schedule as OCs, with 3 weeks of ring usage and 1 week without to produce a withdrawal bleed.

    The vaginal sponge, introduced in 1983 and taken off the market shortly after, is making a comeback. The contraceptive was deemed safe by the FDA. However, the plant it was manufactured in was not. American Home Product’s plant had many problems, such as high levels of bacteria in its air and water, which were felt to be too costly to fix for a product that generated only 17 million dollars yearly in sales. Allendale Pharmaceutical has now bought the patent and equipment and has moved production to a new plant. Allendale Pharmaceutical currently is in the process of sponge production and marketing; however, the company is still awaiting FDA inspection of the plant for adherence to health regulations before it can return the vaginal sponge to the market.

    The vaginal sponge is made of soft disposable polyurethane foam that contains the spermicide nonoxynol-9. It offers an immediate and continuous presence of spermicide throughout a 24-hour period. The polyurethane foam is designed to trap and absorb semen before the entry of sperm into the cervix. Clinical trials have demonstrated an efficacy rate of 89% and 91% for parous and nulliparous women respectively.

    Lea’s Shield is a 1-size-fits-all diaphragmlike device. This device consists of a 1-way valve that allows air to escape during placement, thus creating a suction effect against the cervix. The unilateral direction of the valve permits uterine and cervical fluids to be released into the vaginal canal, but prevents sperm from entering. Currently, it is manufactured in Canada and Europe.

A few potential methods of tubal sterilization are under investigation. One of these new developments includes chemical scarring of the fallopian tubes. The scarring is a result of a combination of phenol and a thickening agent and phenol quinacrine that ultimately leads to blockage of the tubes. Another nonsurgical form of tubal sterilization is by utilizing chemical plugs. Approved for use in Canada, this entails introduction of methyl cyanoacrylate (Krazy Glue) into the fallopian tube. A reversible chemical plug also can be created by the injection of silicone into the fallopian tubes. The silicone eventually hardens but can be removed later. Chemical scarring and plugs are under investigation as potential methods of vasectomy as well.

A pregnancy vaccine is one of the most controversial and exciting forms of contraception under development. The pregnancy vaccine, unlike anti-infective vaccines, stimulates an immune response against one or more host-specific antigens. The targets of the immune response are accessible to the immune system during a finite time period, such as coitus (sperm antigens in the female), egg maturation (zona pellucida antigens), or successful fertilization (chorionic gonadotropin).

    Vaginal foam, cream, suppository, and sponge. This agents must be placed into the vagina before each coital act. They contain a spermicide, usually nonoxynol 9 (or benzalkonium chlorid (“Pharmatex”), that immobilizes or kills sperm on contact; they also provide a mechanical bartrier to sperm. No single type of foam or suppository seem to be more effective than another, but the contraceptive sponge has the advantage of remaining effective for 24 h.

 Condom.  Comdom is the only reversible effective male method other than coits interruptus (withdrawal). If used properly, the conod also provides considerable protection against sexually transmitted diseases and may possibly prevent premalignant changes of the cervix.

 Oral Contraceptive (OC). There are 2 major categories of Ocs: combination and progestogen only. Combination types contain both a synthetic estrogen and a synthetic progestogen and are given continuously for 3 wk. No medication is given in the 4^th wk, to allow for withdrawal bleeding. With progestogen alone, a small dose of a synthetic progestogen is given every day; this regimen, associated with a relavtively high incidennce of irregular bleeding episodes and a pregnancy rate of 2 to 8 % /yr, is recommended only when estrogen is contraindicated-eg, when breast-feeding.

 The benefits of OCs must be weighed against risks for the individual patient Not taking OCs may result in an unwanted pregnancy, and the risk of death associated with normal pregnancy as well as with elective abortion is greater than that associated with Ocs Starting OC treatment: All women receiving OCs should be examined initially, 3 mo later (to determine if BP has changed), and at least annually thereafter. When a personal or family history suggests increased risk of diabetes mellitus or artenosclerotic cardiovascular disease, a 2-h postprandial blood glucose level should be obtained, along with a serum iipid profile that includes total cholesterol, and tnglycende levels. OC use following pregnancy: The woman who has had a term delivery differs from one who has had an abortion in the interval between resumption of ovulation and recurrence of menstruation The first episode of menstrual bleeding following an abortion is usually preceded by ovulation, which generally occurs between 2 and 4 wk. The first menstruation following a term delivery in a nonnursmg mother is usually anovulatory, but occasionally ovulation occurs 4 to 5 wk after delivery Nursing mothers usually do not ovulate until 10 to 12 wk after delivery, but they may ovulate before the first menses. After spontaneous or induced abortion of a fetus of < 12 wk gestation, OCs should be started immediately. After termination of pregnancy between 12 and 28 wk, the start of OCs should be delayed 1 wk. Since the risk of thromboembolism normally increases postpartum and may be enhanced by OCs, patients who have a delivery after 28 wk gestation and are not nursing should delay taking OCs until 2 wk after delivery. During lactation, OCs diminish the amount of milk produced and reduce the concentrations of protein and fat in the milk; also, measur­able amounts of the hormonal compounds can be found in the milk. Therefore, combination OCs are not advised for nursing mothers; progestogen-only formulations should be used. Galactorrhea is an uncommon side effect. No benefits of intermittently stopping therapy have been documented. Thus, OCs need not be stopped for any interval (unless the woman wishes to conceive), as long as she does not develop adverse effects or other contraindications to their use. Healthy women who do not smoke can take low-dose OCs continuously until menopause or age 50. 

Physiology: Because OCs provide negative feedback to the hypothalamus, inhibiting gonadotropm-releasing hormone, the pituitary does not secrete gonadotropins at midcycle < to stimulate ovulation. The endometnum of the uterus becomes thin, and the cervical mu­cus becomes thick and impervious to sperm.

   Side effects and contraindications: Women who develop breakthrough bleeding while taking OCs should be given a combination with a higher ratio of estrogen; le, a more estrogenic formulation. For women who develop amenorrhea, the progestogenic component should be decreased. Many side effects, such as nausea, breast tenderness, fluid retention, higher BP, and depression, are related to the dose of estrogen. Progestogens produce anabolic effects, such as weight gain, acne, and a sensation perceived by some women as nervousness. Levonorgestrel is 10 to 20 times as potent per unit weight as the other 3 progestogens used in OCs—norethindrone, norethindrone acetate, and ethynodiol diace-tate, which are about equal in potency.

    In addition to affecting the female genital tract, the metabolic activities of synthetic hor­monal components of OCs affect nearly every other organ system. Senous complications, however, are relatively rare.

 Absolute contraindications to OCs besides smoking after age 35 include pregnancy, active liver disease, hyperiipidemia, uncontrolled hypertension, diabetes mellitus with vascular changes, prolonged immobilization of a lower extremity, and a history of thromboembolic phenomena, thrombophlebitis, coronary artery disease, stroke, sickle cell disease, estrogen-dependent cancer, liver adenoma, and cholestatic jaundice of pregnancy.

 Relative contraindications include depression, migraine headache, oligomenon-hea, undiagnosed amenorrhea, and heavy cigarette smoking under age 35.

 Inhibition of ovulation persists in a few women after they stop taking the tablets, but OCs do not cause permanent sterility or affect the outcome of pregnancies conceived any time after their discontinuance. OCs taken early in pregnancy do not adversely affect the fetus.

 Intrauterine Device (1UD)

 lUDs have some advantages over OCs: their effects are limited to the female genital tract, and insertion requires only one decision by the patient. Pregnancy rates at the end of 6 yr of use with this device are < 2%. Although it had been advised that the 1UD be inserted during menstruation, the device can be inserted at any time in the cycle, provided the woman is not pregnant. A high fundal insertion must be obtained for the device to be effective.

 There is no need to change a plastic unmedicated 1UD unless the patient devel­ops increased bleeding after it has been in place for > 1 yr. The roughness of calcium salts deposited on the plastic over time, however, can cause ulceration and bleeding of the endometrium. If increased bleeding develops after 1 yr or more, the old 1UD should be removed and a new one inserted.

Physiology: A sterile tissue reaction in the endometrial cavity is generally accepted as the main cause of the contraceptive effect. Bacterial contamination is present for 24 h after insertion of an 1UD, and although the endometrial cavity rapidly becomes sterile, inflam­mation persists after the bacterial infection disappears. Breakdown products of intrauterine neutrophils are toxic to the sperm and blastocyst; this is the major means by which lUGl prevent fertilization. The inflammatory foreign body reaction ceases when the 1UD is re­moved. The monthly incidence of conception in the first year after removal of an 1UD is the same as after stopping the use of condoms or diaphragms; at the end of 1 yr, 90% of women who wish to conceive have done so.

Side effects and complications: Bleeding and pain are the major medical reasons for removing an 1UD; these problems account for > 50% of all discontinuances and occur in about 15% of patients during the first year and 7% during the second year of use. Insertion during menses is usually less painful than at other times in the menstrual cycle.

The expulsion rate for most devices is greatest during the first year (about 10%) and occurs most frequently in the first few months after insertion. The expulsion rate is higher in vounser women and iulligravidas. If another 1UD is inserted, there’is a good chance it will be retained. About 20% of expulsions are unnoticed and can be followed by an unwanted pregnancy; therefore, a plastic string should be attached to the IUD so that the user can check periodically, especially after menses, to see that the device has not been expelled.

    Perforation of the uterus is a potentially serious but uncommon problem; for devices in current use it occurs in about 1/1000 insertions. Perforation occurs during insertion. Sometimes only the distal portion of the IUD penetrates the uterine muscle during insertion; then uterine contractions during the next few months force the IUD into the peritoneal cavity. Perforation should always be suspected if a patient states she cannot feel the string but did not notice that the device was expelled. If the device or the tail is not visible after pelvic examination, the uterine cavity should be probed (unless pregnancy is suspected). If the IUD cannot be felt with a uterine sound or biopsy instrument, a sonogram or a lateral x-ray with contrast medium inside the uterine cavity should be obtained (an IUD located in the cul-de-sac can be missed on an ordinary anteroposterior film). All intraperitoneal lUDs should be removed, as they may cause bowel adhesions. Extrauterine lUDs containing copper can cause severe intraperitoneal reactions and should be removed promptly, usually via laparoscopy.

   Bacterial contamination of the endometrial cavity occurs at the time of insertion and clears after 24 h. IUD appendages do not provide continuous access for bacteria to enter the endometrial cavity. However, an IUD should not be inserted in a patient with clinical evidence of salpingitis, since additional bacteria would be introduced. Most infections oc­curring after an IUD has been in place for s 30 days are sexually transmitted and are not caused by the IUD; they can be treated without removing it, unless the infection is severe or the patient is pregnant. Although IUD users have a three-fold greater incidence of clini­cal salpingitis thaonusers, the increased risk with copper lUDs occurs during only the first 4 mo after insertion and probably is related to bacteria introduced during insertion. Prophylactic systemic antibiotic use following insertion is not cost-effective. An IUD should not be inserted if there is clinical evidence of cervicitis. Since the shield type of IUD with its multifilament tail string has been associated with increased risk of salpingitis, all lUDs of this type should be removed. Individuals at high risk for developing salpingitis, including those with a prior history of pelvic inflammatory disease, nulliparous women < 25 yr of age, and women with multiple sexual partners, should not use lUDs.

 The incidence of congenital defects in babies born to mothers with an IUD in place is no greater than that of the general population; nor is the incidence of fetal death increased, but the incidence of spontaneous abortion is significantly higher (about 55%). If a woman who becomes pregnant with an IUD in place wishes to continue the pregnancy and the appendage is visible, the IUD should be removed, since the abortion rate is lower after removal of the device. The IUD will not be located in the amniotic sac, since implantation does not occur immediately adjacent to the device. If the appendage is not visible, the uterus should not be probed in an attempt to remove the IUD. A number of serious and even fatal systemic infec­tions have been reported in women who became pregnant with the IUD (particularly the shield type with its multifilament tail) in place; thus, it is recommended that the IUD be removed if pregnancy occurs and the string is visible. If the string is not visible, removal will result in abortion. Therefore, if the patient refuses removal and wants to retain the pregnancy, she must be warned of the possibility of sepsis and should report symptoms of infection promptly. If uterine infection during pregnancy occurs with an IUD in place, appropriate antibiotics should be given and the endometrial cavity should be evacuated.

 

    Emergency contraception

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Emergency contraception is a birth control method to prevent pregnancy in women:

• After a sexual assault or rape

• When a condom breaks or a diaphragm slips out of place

• When a woman forgets to take birth control pills

• When you have sex and do not use any birth control

Information

Emergency contraception most likely works by preventing or delaying the release of an egg from a woman’s ovaries. This method prevents pregnancy in the same way as regular birth control pills.

TYPES OF EMERGENCY CONTRACEPTION

Two emergency contraceptive pills may be bought without a prescription:

• Plan B One-Step is a single tablet that contains 1.5 mg of levonorgestrel.

• Next Choice is taken as two doses, which each contain 0.75 mg of levonorgestrel. Both pills can be taken at the same time or as two separate doses 12 hours apart.

• Either may be taken for up to 5 days after unprotected intercourse.

Ulipristal acetate (ella) is a new type of emergency contraception pill that requires a prescription from a health care provider.

• Ulipristal is taken as a single tablet.

• It may be taken up to 5 days after unprotected sex.

Two other methods that may be used to prevent pregnancy after unprotected sex are:

• Birth control pills. Talk to your health care provider about the correct dosage. In general, you must take 2 – 5 birth control pills at the same time to have the same protection.

• A copper-releasing intrauterine device (IUD) may be used as an alternative emergency contraception method. It must be inserted by your health care provider within 5 days of having unprotected sex. Your doctor can remove it after your next period, or you may choose to leave it in place to provide ongoing birth control.

MORE ABOUT EMERGENCY CONTRACEPTIVE PILLS

Women ages 17 and older can buy Plan B One-Step and Next Choice at a pharmacy without a prescription or visit to the doctor. Younger girls need to contact a health care provider to get a prescription for these pills.

Emergency contraception works best when you use it within 24 hours of having sex. However, it may still prevent pregnancy for up to 5 days after you first had sex.

Emergency contraception may cause side effects. Most are mild. They may include:

• Changes in menstrual bleeding

• Fatigue

• Headache

• Nausea and vomiting

After you use emergency contraception, your next menstrual cycle may start earlier or later than usual. Your menstrual flow may be lighter or heavier than usual.

• Most women get their next period within 7 days of the expected date.

• If you do not get your period within 3 weeks after taking emergency contraception, you might be pregnant. Contact your health care provider.

Sometime, emergency contraception does not work. However, research suggests that emergency contraceptives have no long-term effects on the pregnancy or developing baby.

OTHER IMPORTANT FACTS

You should not use emergency contraception if:

• You think you have been pregnant for several days

• You have vaginal bleeding for an unknown reason (talk to your health care provider first)

You may be able to use emergency contraception even if you cannot regularly take birth control pills. Talk to your health care provider about your options.

Emergency contraception should not be used as a routine birth control method. It is less effective at preventing pregnancies than most types of birth control.

 

Reversible Methods of Birth Control

   Intrauterine Contraception

 

 

·        Copper T intrauterine device (IUD) —This IUD is a small device that is shaped in the form of a “T.” Your doctor places it inside the uterus to prevent pregnancy. It can stay in your uterus for up to 10 years. Typical use failure rate: 0.8%.

·        Levonorgestrel intrauterine system (LNG IUD)—The LNG IUD is a small T-shaped device like the Copper T IUD. It is placed inside the uterus by a doctor. It releases a small amount of progestin each day to keep you from getting pregnant. The LNG IUD stays in your uterus for up to 5 years. Typical use failure rate: 0.2%.

 

Hormonal Methods

·        Implant—The implant is a single, thin rod that is inserted under the skin of a women’s upper arm. The rod contains a progestin that is released into the body over 3 years. Typical use failure rate: 0.05%.

·        Injection or “shot”—Women get shots of the hormone progestin in the buttocks or arm every three months from their doctor. Typical use failure rate: 6%.

 

·        Combined oral contraceptives—Also called “the pill,” combined oral contraceptives contain the hormones estrogen and progestin. It is prescribed by a doctor. A pill is taken at the same time each day. If you are older than 35 years and smoke, have a history of blood clots or breast cancer, your doctor may advise you not to take the pill. Typical use failure rate: 9%.

·        Progestin only pill—Unlike the combined pill, the progestin-only pill (sometimes called the mini-pill) only has one hormone, progestin, instead of both estrogen and progestin. It is prescribed by a doctor. It is taken at the same time each day. It may be a good option for women who can’t take estrogen. Typical use failure rate: 9%.

 

 

·        Patch—This skin patch is worn on the lower abdomen, buttocks, or upper body (but not on the breasts). This method is prescribed by a doctor. It releases hormones progestin and estrogen into the bloodstream. You put on a new patch once a week for three weeks. During the fourth week, you do not wear a patch, so you can have a menstrual period. Typical use failure rate: 9%, but may be higher in women who weigh more than 198 pounds.

·        Hormonal vaginal contraceptive ring—The ring releases the hormones progestin and estrogen. You place the ring inside your vagina. You wear the ring for three weeks, take it out for the week you have your period, and then put in a new ring. Typical use failure rate: 9%.

·        Emergency contraception—Emergency contraception is NOT a regular method of birth control. Emergency contraception can be used after no birth control was used during sex, or if the birth control method failed, such as if a condom broke.

o   Women can have the Copper T IUD inserted within five days of unprotected sex.

o   Women can take emergency contraceptive pills up to 5 days after unprotected sex, but the sooner the pills are taken, the better they will work. There are three different types of emergency contraceptive pills available in the United States. Some emergency contraceptive pills are available over the counter.

 

  Barrier Methods 

·        Diaphragm or cervical cap—Each of these barrier methods are placed inside the vagina to cover the cervix to block sperm. The diaphragm is shaped like a shallow cup. The cervical cap is a thimble-shaped cup. Before sexual intercourse, you insert them with spermicide to block or kill sperm. Visit your doctor for a proper fitting because diaphragms and cervical caps come in different sizes. Typical use failure rate: 12%. 

 

 

 

 

·         Male condom—Worn by the man, a male condom keeps sperm from getting into a woman’s body. Latex condoms, the most common type, help prevent pregnancy, and HIV and other STDs, as do the newer synthetic condoms. “Natural” or “lambskin” condoms also help prevent pregnancy, but may not provide protection against STDs, including HIV. Typical use failure rate: 18%.
Condoms can only be used once. You can buy condoms, KY jelly, or water-based lubricants at a drug store. Do not use oil-based lubricants such as massage oils, baby oil, lotions, or petroleum jelly with latex condoms. They will weaken the condom, causing it to tear or break.

·        Female condom—Worn by the woman, the female condom helps keeps sperm from getting into her body. It is packaged with a lubricant and is available at drug stores. It can be inserted up to eight hours before sexual intercourse. Typical use failure rate: 21%, and also may help prevent STDs.

 

·        Spermicides—These products work by killing sperm and come in several forms—foam, gel, cream, film, suppository, or tablet. They are placed in the vagina no more than one hour before intercourse. You leave them in place at least six to eight hours after intercourse. You can use a spermicide in addition to a male condom, diaphragm, or cervical cap. They can be purchased at drug stores. Typical use failure rate: 28%.

Fertility Awareness-Based Methods

·        Natural family planning or fertility awareness—Understanding your monthly fertility pattern can help you plan to get pregnant or avoid getting pregnant. Your fertility pattern is the number of days in the month when you are fertile (able to get pregnant), days when you are infertile, and days when fertility is unlikely, but possible. If you have a regular menstrual cycle, you have about nine or more fertile days each month. If you do not want to get pregnant, you do not have sex on the days you are fertile, or you use a barrier method of birth control on those days. Failure rates vary across these methods. Overall, typical use failure rate: 24%.

 

   Permanent Methods of Birth Control

  Contraceptive sterilization is a permanent, safe, and highly effective approach for birth control. These methods are meant for people who are sure that they do not desire a pregnancy in the future.

The following methods have a typical use failure rate of less than 1%.

Although most women and men who undergo contraceptive sterilization do not regret having had the procedure, the permanence of the method is an important consideration, as regret has been documented in studies. For example, the U.S. Collaborative Review of Sterilization (CREST) study found that women who were younger at the time of the procedure were more likely to experience regret. Read the following to learn more:

o   Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93:889–895.

o      Regret following female sterilization at a young age: a systematic review Contraception. 2006;73(2):205–210.

o      Abstracts of publications from the Collaborative Review of Sterilization (CREST) study.  

An additional issue addressed by the CREST study was the question of whether women who underwent contraceptive sterilization developed a “post-tubal ligation syndrome” of menstrual abnormalities, something that had been debated for years. Results indicated that menstrual abnormalities were no more common among women who had undergone tubal sterilization than among women who had not.

When considering a vasectomy, it’s important to understand that failures can occur. CDC research has estimated there is a probability of 11 failures per 1,000 procedures over 2 years; half of the failures occurred in the first three months after the vasectomy, and no failures occurred after 72 weeks.¹ CDC research also examined regret among women whose partner underwent a vasectomy.² In interviews with female partners of men who received vasectomies, CDC found that while most women did not regret their husband’s vasectomies, the probability of regret over 5 years was about 6%. This is why it is important to know facts about this and other permanent forms of birth control before making a decision.