Contraception

Contraception is an important part of family practice. It is important to counsel patients, especially adolescents and post-partum women, on regular clinic visits. Along with contraception counselling patients should be educated on risk for sexually transmitted infections. There are multiple contraception options that are available that can be tailored to each individual patient.

Male Condoms

 * Latex: most popular barrier method. Acts as a barrier sheath
 * Polyurethane: more sensitivity, thinner, compatible with oil based lubricants
 * Lambskin: not recommended for protection against STI
 * Effectiveness: perfect use 97%, typical use 86%. Highest failure rate ages 20-24
 * Benefits: protects against STIs, low cost
 * Disadvantages: slippage/breakage, decrease sensitivity, allergy

Female Condoms

 * Polyurethane sheath inserted into the vagina
 * Effectiveness: perfect use 95%, typical use 80%
 * Benefits: controlled by female (empowerment), can be inserted up to 8 hours prior to intercourse, protects against STIs
 * Disadvantages: sometimes difficult to insert, cost

Cervical Cap

 * Intravaginal silicone cap that covers the cervix preventing sperm penetrance
 * Used with spermicide
 * Effectiveness: perfect use nulliparous (92%)/multiparous (74%); typical use 80% and 60% respectively
 * Benefits: may offer protection against cervical infections
 * Disadvantages: must be fitted by physician, does not prevent STIs
 * DO NOT USE in patients with PID, cervical/uterine cancer, current vaginal/cervical infections. Increased risk of toxic shock syndrome

Diaphragm

 * Latex cap that covers the cervix. Should always be used with spermicide
 * Effectiveness: perfect use 94%, typical use 80%
 * Benefits: potential decrease risk of STI (not HIV), women empowerment
 * Disadvantages: need to be fitted by physician, increase risk of urinary tract infection, increase risk of bacterial vaginosis, can be associated with toxic shock syndrome

Contraceptive Sponge

 * Disposable sponge with spermicide use intravaginally. Should not be primary form of contraception. Meant as an adjunct (e.g. male condom)
 * Effectiveness: perfect use 90%, actual use nulliparous 80%, multiparous 60%
 * Benefits: one size fits all, contraception for 12 hours after insertion
 * Disadvantages: increase risk of toxic shock syndrome, no STI protection, recurrent yeast infections



Rhythm Method

 * Use calendar to track menstrual cycle
 * No sexual intercourse around days of ovulation

Temperature Method (Basal body temperature)

 * Take temperature daily in a.m. Temp elevation x 3 days in a row suggests post-ovulatory phase with less change of conception
 * If used in conjunction with cervical mucous changes = most effective of natural methods (75% effective with typical use)
 * Benefits: alternative to hormonal therapy, promotes body awareness, consistent with many religious belief
 * Disadvantages: no protection from STI, difficult to train, time to learn

Lactational Amenorrhea Method

 * Method for women exclusively breastfeeding for first 6 months post-partum
 * Need to breastfeed q4 hours while awake and q6 hours overnight and no menses

Withdrawal Method

 * Male partner withdraws penis from woman's vaginal before ejaculation

Abstinence

 * Avoidance of vaginal intercourse

Combined Contraceptives
Combined CPs contain both progesterone and estrogen in varying concentrations. Of the women that use contraception in Canada 32% use the combined OCP (oral pill). Fertility is restored in 1-3 months after stopping combined contraceptives. Options available for combined contraceptives include: oral contraceptive pill, vaginal ring (nuvaring), transdermal patch (evra).

Mechanism of Action

 * Inhibit ovulation by suppressing gonadotropin
 * Endometrial atrophy - inhibits implantation
 * Increased cervical mucous - prevent sperm penetration
 * +/- Change in peristalsis of fallopian tube - interferes with ovum/sperm transport

Absolute Contraindications

 * < 6 weeks postpartum if breastfeeding
 * Smoker > 35 years old with >15 cigs/day
 * HTN sBP>160 or dBP>100
 * Current or past history of VTE
 * Heart disease (ischemic or complicated valvular disease - pulmonary HTN, atrial fibrillation, subacute bacterial endocarditis)
 * History of CVA
 * Migraine headache with focal neurological symptoms
 * Current Breast cancer
 * Diabetes with retinopathy/nephropathy/neuropathy
 * Severe cirrhosis, liver tumor
 * Undiagnosed vaginal bleeding

Relative Contraindications

 * Smoker > 35 years of age and smokes <15 cigarettes/day
 * Controlled HTN, BP 140-160/90-99
 * Migraine HA > 35 years of age
 * Symptomatic gallbladder disease
 * Mild cirrhosis
 * History of OCP related cholestasis
 * Users of medications that may interfere with combined OCP metabolism

Benefits

 * Contraception
 * Cycle regulation, decreased menstrual flow, decreased dysmenorrhea, decreased perimenopausal symptoms, decrease salpingitis
 * Decreased acnes, decreased hirsutism
 * Decreased endometrial Ca, decreased ovarian Ca
 * Decreased risk of fibroids
 * Increased bone mineral density
 * ?Fewer cases of benign breast disease, less colorectal Ca

Side effects

 * S/E most common in first 3 months
 * Irregular bleeding (10-30%)
 * Breast tenderness
 * Nausea
 * Not proven: weight gain, mood changes

Risks

 * Venous thromboembolism (3-4X higher. 1/10000 users per year. Highest risk in first year of use
 * Myocardial infarction (estrogen dose related) 3x risk - often with estradiol >50ug
 * CVA (estrogen dose related) 2X risk - often with estradiol >50ug
 * Gallbladder disease (increase cholic acid in bile, no increase risk of gallstone formation)
 * Breast cancer (controversial)

Combined oral contraceptive Pill

 * Effectiveness with perfect use is 99.9% with typical use 92-97%.
 * Monphasic refers to fixed amounts of estrogen and progestin), biphasic (fixed amount of estrogen, progestin increases in second half of cycle), and Triphasic (estrogen may be fixed or variable, progestin increases in three equal phases)
 * Two types of estrogen are used in the OCP (estradiol and mestranol-prodrug). Many progestins are available with varying estrogenic, anti-estrogenic, and androgenic activity. Progestins are normally divided into estrane (norethindrone, ethynodiol diacetate) and gonane (levonorgestrel, desogestrel, norgestimate)
 * Prescribing:


 * ​ Start low dose ethinyl estradiol <35mc
 * Start date:
 * In first 5 days of menstrual cycle - no backup method needed
 * First Sunday after menses (to avoid weekend periods) - need backup contraception
 * Quick start (start today) - backup method needed for first week (improved compliance
 * Never exceed 7 day pill free interval between packs
 * Discuss emergency contraception, risk of STIs
 * Troubleshooting:
 * Breakthrough bleeding:
 * Encourage continued use. Often subsides after 3 cycles.
 * If persists R/O other causes of PV bleeding.
 * Management: supplemental estrogen therapy (1.25mg conjugated estrogen PO x 7 days) or trial of another OCP with different progestin
 * Missing pills:
 * 1 pill delayed for <24 hours in any week--> take ASAP and continue regular schedule
 * During week 1 missing 1 pill or more --> Take one pill ASAP then continue taking one pill daily. Back up protection x 7 days
 * During week 2-3
 * < 3 pills: Take one pill ASAP, continue regular schedule, start new pack immediately WITHOUT hormone free period
 * > 3 pills: As above + back-up contraception x 7 days

Continuous use of combined OCPs

 * Take combined oral contraceptive pill (monophasic) pill packages continuously for 2-4 pill packages with hormone free interval for 4-5 days. Other options include seasonal/seasonique
 * Advantages: decrease pelvic pain, headache, bloating, breast tenderness, improved endometriosis and PCOS
 * Disadvantages: not many studies on long term safety, often have break through bleeding (will decrease over time)

Transdermal Patch (Evra)

 * Patch worn for 3 weeks (changed q week at same time) with 1 week patch free. Placed on buttocks, stomach, back or upper arms
 * Effectiveness: perfect use 99%, typical 97%. Keep in fridge.
 * Benefits: as above for combined OCP,  good for patients that have difficulty remembering OCP
 * Disadvantages: sticks 98% of the time, no protection from STIs, cost, skin irritation
 * Starting the patch: start on first day of menses
 * Troubleshooting:
 * Check patch daily. If starts to come off attempt to reattach x 10 seconds. If no success --> change patch. Continue regular schedule
 * Patch falls off > 24 hours: put new patch on right away, start new 4 week cycle. Back up protection x 7 days
 * Forget to change patch:  x1-2 days: remove, apply new patch, continue regular schedule. If > 2 days: start new four week cycle with new patch + back up contraception x 7 days
 * Forget to remove patch for patch-free week: remove when you remember and start next cycle as previously scheduled
 * Forget to put on patch after patch-free week: put on as soon as you remember. Back up contraception x 7 days

Vaginal Ring (Nuvaring)

 * Soft, flexible, clear plastic ring is Inserted in the vagina x 3 weeks then 1 week ring free (**no more than 7 days ring free**)
 * Effectiveness: 99% perfect use, 95-97% with typical. Keep in fridge.
 * Benefits: good for patients that have difficulty remembering OCP
 * Disadvantages: vaginal irritation/discharge
 * Relative contraindication: uterine prolapse or vaginal stenosis
 * Troubleshooting:
 * Ring falls out: < 3 hours rinse and reinsert ASAP. If> 3 hours reinsert, back up protection x 7 days. If ring is out for more than 3 hours it must stay in at least svcen more days even if that exceeds the 21 day total that month
 * Forget to remove: < 28 days (remove ring, 7 day ring free period and then insert next ring). If > 28 days (remove ring ASAP, insert new ring right away and use backup form of birth control x 7 days)
 * Forget to insert: Insert ring as soon as you remember and use backup contraception x 7 days

Algorithm for Missed Combined Contraception

 * https://www.inspq.qc.ca/Data/Sites/1/SharedFiles/ContraceptionHormonale/OCC-ALGOdecisionnel_Anglais.pdf

Injectable Progestin (depo-provera)

 * Effectiveness: 99.7%
 * Mechanism of action: inhibits secretion of gonadotropins, suppresses ovulation, increases cervical mucous production and induces endometrial atrophy
 * Injected  150mg q12 weeks IM deltoid or gluteus, useful in women with contraindications to estrogen
 * Contraindications: pregnancy, unexplained vaginal bleeding, current diagnosis of breast Ca. Relative: severe cirrhosis, active viral hepatitis, benign hepatic adenoma
 * Benefits: contraception, amenorrhea, reduced risk of endometrial Ca, decrease symptoms of endometriosis/PMS/chronic pelvic pain, decreased incidence of seizures, ?decrease risk of PID, ?decrease risk of sickle cell crisis
 * Side effects: Irregular PV bleeding, HA, acne, decrease libido, nausea, breast tenderness, weight gain
 * Risks: delay in return to fertility (9 months), reduced bone mineral density
 * Prescription: administer during first 5 days of menses, counsel on dietary/lifestyle to affect peak bone mass
 * Troubleshooting:
 * Irregular bleeding (if > 6 months): R/O other etiology
 * Increase dose 225-300mg for 2-3 injections or increase the frequency of dosing
 * Supplemental estrogen therapy (PO or transdermally)
 * NSAID x 10 days
 * Adding combined OCP for 1-3 months
 * Late injection:
 * < 14 weeks: give next injection)
 * > 14 weeks: check for pregnancy, give next injection, back up contraception x 2 weeks

Progestin Only Pill

 * Micronor 28 tablets - 0.45 mg of norethindrone
 * Effectiveness: perfect use 99.5%, typical use 90-95%
 * Mechanism of action: cervical mucous changes, ovulation partially suppressed, endometrial changes
 * Contraindications: pregnancy, current breast Ca. Relative: active viral hepatitis, liver tumors
 * Benefits: useful for patients that cannot tolerate combined pill, amenorrhea
 * Disadvantages: needs to be taken every day at the same time (within 3 hours)
 * Side effects: same as injectable
 * Prescription: can be started at any time as long as pregnancy r/o, take every day without pill free period, backup contraception x 7 days
 * Troubleshooting:
 * Irregular bleeding: r/o other etiology of PV bleeding. Can consider: NSAIDs, changing to a Combined OCP, supplemental estrogen
 * Missed pill: If pill missed, take ASAP. If >3hours --> backup contraception x48h. If missed 2+ pills -->take 2 pills daily x 2 days and use backup contraception x 48h

Intrauterine Devise (IUD)

 * Effectiveness: failure rate- 0.09/100, ectopic 0.02/100
 * Mechanism: prevents fertilization and implantation

Absolute Contraindications

 * Pregnancy
 * Current, recurrent, or recent (within 3 months) PID or STI
 * Puerperal sepsis
 * Immediate post-septic abortion
 * Abnormal uterine cavity
 * Unexplained vaginal bleeding
 * Cervical or endometrial cancer
 * Malignant trophoblastic disease
 * Breast Cancer (for mirena/jaydess)
 * Copper allergy (for copper IUD)

Relative Contraindications

 * Risk factors for STIs and HIV
 * From 48 hours to 4 weeks post-partum
 * Ovarian cancer
 * Benign gestational trophoblastic disease
 * Immunosuppression

Side Effects

 * Irregular PV bleeding, dysmenorrhea, progesterone s/e (headache, nausea, low mood, acne, breast tenderness), functional ovarian cysts (in mirena/jaydess)

Risks

 * Uterine perforation, infection, expulsion (2-10%, often in first year), failure (risk of spontaneous abortion if IUD left in place), ectopic

Insertion

 * Obtain consent. Discuss risks/benefits
 * Counsel r.e. side effects
 * IUD can be inserted at any time during menstrual cycle after R/O pregnancy
 * Consider cervical swabs for STIs

Troubleshooting

 * Lost strings: speculum exam and R/O pregnancy. Explore cervical canal.
 * If not found --> Ultrasound to assess location.
 * If not evident on ultrasound --> Plain abdo Xray to r/o uterine perforation
 * Pregnancy: if wishes to terminate --> leave in place. If wishes to continue removed if possible with consultation w/ gynecology
 * STI: Treat with Abx. If PID-->remove
 * Removal: grasp with forceps. Unable-->refer to gyne
 * Amenorrhea: r/o pregnancy
 * Pain and abnormal bleeding: r/p expulsion/perforation, pregnancy and infection. Can consider Rx with NSAIDs.

Copper IUD

 * Mechanism: sperm transport affected. No change in ovulation.
 * No hormones
 * S/E: menorrhagia

Mirena IUD

 * Mechanism: cervical mucous changes. May inhibit ovulation.
 * Maximum duration of use: 5 years
 * Progesterone only
 * Benefit: decrease menorrhagia

Jaydess IUD

 * Maximum duration of use: 3 years
 * Smaller T-frame dimensions
 * Progesterone only

Surgical Contraception

 * Vasectomy
 * Tubal ligation
 * Both require referral

Post-Partum Contraception

 * If non-breastfeeding- OCP within 3 weeks post-partum
 * Breastfeeding:
 * IUD at 6 weeks post-partum (as higher risk earlier for expulsion and uterine perforation
 * mini pill at 6 weeks post-partum
 * Lactational amenorrhea method (natural method): first 6 months post partum if exclusively breastfeeding q4 hours while awake and q6 hours overnight and no menses
 * Combined OCPs: can diminish breast milk quality and quantity. Should not be used unti breast feeding well established > 6 weeks postpartum

Emergency Contraception

 * Plan B (85% effective): 2 doses of 750mcg levonorgestrel 12 hours apart
 * Yuzpe method (75% effective): 2 doses of 100mcg ethinyl estradiol and 500mcg levonorgestrel 12 hours apart
 * Both Plan B and Yuzpe can be taken up to 72 hours after intercourse. S/E:++nausea/vomit/dizziness/fatigue
 * Insertion of copper IUD (approaches 100% effective): inserted up to 7 days after unprotected intercourse

Resources
http://www.sexualityandu.ca/birth-control/birth_control_methods_contraception

http://sogc.org/wp-content/uploads/2013/01/143E-CPG2-March2004.pdf

https://www.inspq.qc.ca/Data/Sites/1/SharedFiles/ContraceptionHormonale/OCC-ALGOdecisionnel_Anglais.pdf

https://www.plannedparenthood.org/

http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm