+

Contraceptive MethodsAlison PittmanPGY2 Family MedicineCivic Family Health Team

+Outline

Introduction

Choosing a Method of Contraception

Natural Methods

Non-Hormonal Methods

Hormonal Methods

+Contraception

Patients often have questions about contraception but aren’t sure which type they want

Some reasons why patients will ask about contraception: Control over timing of pregnancy Avoidance of unintended pregnancy Protection from STI infection Noncontraceptive health benefits (hormonal options)

Discuss all forms with patients to find which method will fit their needs

+Choosing a Method Convenience

Duration

Reversibility

Efficacy

Cost

Side effects

Accessibility

STI protection

Effect on uterine bleeding

Noncontraceptive benefits

Contraindications

+Natural Methods

Abstinence

Fertility Awareness/Natural Family Planning

Rhythm (Calendar) Method

Withdrawal

+Non-Hormonal Methods

Surgery Tubal Ligation Vasectomy

Barriers Male Condom

Intrauterine Contraceptive Device (Copper IUD)

Others Spermicide Contraceptive sponge Lea contraceptive Cervical Cap Diaphragm

+Copper IUD

T-shaped device with copper wire that is inserted into the uterus

Changes intrauterine chemistry, prevents fertilization and destroys sperm

EfficacyFails in <1 in 100 users per year

+Copper IUD

Benefits:

Up to 5 years of contraception

No need to remember pills

Can use while breast feeding

No hormone exposure

Decreased risk of endometrial ca

+Copper IUD

Relative Contraindications High risk for STIs Immunocompromised Ovarian cancer

Absolute Contraindications Pregnancy Current or recent PID or

STI Distorted uterine cavity Unexplained vaginal

bleeding Cervical or endometrial

cancer Copper allergy

+Copper IUD

Side effects

Increased bleeding

Dysmenorrhea

Risks

Uterine perforation

Infection

Expulsion

Failure

Risk of ectopic pregnancy

+Copper IUD

Who could benefit?Postpartum and breastfeeding

Hormone concernsDifficulty remembering pills

+Hormonal Methods

Combined oral contraceptive

Contraceptive patch

Vaginal ring

Progestin-only oral

contraceptive

Injection

Hormonal IUD

+Combined Oral Contraceptive Pills

Combined OCPs contain estrogen and progestin

Multiple mechanisms of action

Efficacy99.9% with perfect useUser failure rates 3-8%

+OCP – Non-Contraceptive Benefits Cycle regulation

menstrual flow

BMD

dysmenorrhea

perimenopausal symptoms

acne

hirsutism

ovarian cancer

endometrial cancer

risk of fibroids

Fewer ovarian cysts

+OCP – Absolute contraindications

Pregnancy <6 weeks postpartum (if

breastfeeding) Smokers >35y/o (>15

cig/day) Hypertension (>160/100) History of VTE IHD Previous CVA Valvular heart disease

Migraine headache with neurologic symptoms

Breast cancer (current) Severe cirrhosis Liver tumour

+OCP – Relative Contraindications

Smokers >35y/o (<15 cig/day)

Controlled hypertension

Migraines >35y/o

Symptomatic gallbladder disease

Mild cirrhosis

Contraindicated medications

+OCP – Side Effects and Risks

Side Effects

Irregular bleeding

Breast tenderness

Nausea

Weight gain

Mood changes

RisksVTEMICVAGallbladder diseaseBreast cancerCervical cancer

+OCP - Disadvantages

Compliance issues

No STI protection

Effectiveness may be affected by other medications

+OCP – Who could benefit?

Irregular cycles

Heavy bleeding

Dysmenorrhea

Acne

Otherwise healthy

Good compliance

+Contraceptive Patch

Transdermal patch that

continuously releases estrogen

and progestin into the bloodstream

Each patch is worn for 7 days.

Week 4 is patch-free

99.7% effectiveness with perfect

use

91% effectiveness with typical use

+Contraceptive Patch

Advantages Improved adherence Serum hormone levels

remain in contraceptive range for up to 9 days

Reversible

Disadvantages Not as effective >90kg Possible skin irritation

+Vaginal Ring

Flexible, transparent ring placed

in the vagina that delivers

estrogen and progestin over a 3

week period

99.7% effective with perfect use

91% effective with typical use

+Vaginal Ring

AdvantagesConvenientComplianceReversible

DisadvantagesVaginal irritationBreakthrough

bleeding

+Patch and Ring

Who could benefit?

Difficulty

remembering pills

No contraindications

Not interested in IUD

+Progestin-only oral contraceptive

Daily pill that does not contain any estrogen, just progestin

Thickens cervical mucous and changes the lining of the uterus, affecting implantation

40% of women continue to ovulate

99.5% effective with perfect use

90-95% effective with typical use

+Progestin-only oral contraceptive

Absolute contraindications

Pregnancy

Current breast cancer

Relative contraindications

Active viral hepatitis

Liver tumours

+Progestin-only oral contraceptive

Non-contraceptive benefits May decrease menstrual flow May decrease menstrual

cramping and PMS

Advantages Use in women who can’t take

estrogen Women >35 who smoke Breastfeeding

+Progestin-only oral contraceptive

Side effects

Irregular bleeding

Hormonal side effects

Headache/bloating/acne/breast tenderness

Disadvantages

Must be taken at the same time every day

No STI protection

+Injection

Injectable progestin (Depo-Provera) inhibits secretion of pituitary gonadotropins, suppressing ovulation

99.7% effective

Absolute contraindications Pregnancy Current breast cancer

Relative contraindications Severe cirrhosis Active viral hepatitis Benign hepatic adenoma

+Injection

Non-contraceptive benefits Amenorrhea (in 50%) with decreased dysmenorrhea Decreased risk of endometrial cancer, endometriosis

symptoms, PMS, chronic pelvic pain

Advantages Injection only needed every 12-13 weeks Can be used while breastfeeding

+Injection

Side effects Weight gain Mood effects Hormonal side effects

Risks Delayed return to

fertility ~9 months

Decreased BMD VTE; CAD; CVA

+Hormonal IUD

Intrauterine small T-shaped frame with levonorgestrel

No estrogen

Slowly releases hormone

Endometrial decidualization, glandular atrophy, thickened cervical mucous

99.9% effective

5 years (Mirena) or 3 years (Jaydess)

+Hormonal IUD

Side effects Reduction in menstrual blood loss More bleeding soon after insertion,

which decreases Some hormonal effects

Depression, acne, headache, tenderness

Functional ovarian cysts

Advantages Effective Compliance

Disadvantages Requires trained clinician for insertion

and removal

+In conclusion…

There are many contraceptive options available to our patients

Take a patient’s health, lifestyle, cultural beliefs and compliance habits into account when discussing their options

Be familiar with side effects and contraindications

+Questions?

+References

The Society of Obstetricians and Gynaecologists of Canada (SOGC) (2012)  Birth Control http://www.sexualityandu.ca/

Association of Reproductive Health Professionals ( June 2014) Choosing a Birth Control Method https://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/choosing

Black, A., Francoeur, D., Rowe, T. et al. (2004) Canadian Contraception Consensus. JOGC, Volume 143 (part 1 of 3; February 2004) 143 - 156

Black, A., Francoeur, D., Rowe, T. et al. (2004) Canadian Contraception Consensus. JOGC, Volume 143 (part 2 of 3; March 2004) 219 – 254

Trussell, J., Wynn, L. Reducing unintended pregnancy in the United States. Contraception. 2008;77(1):1

+Tubal Ligation

Surgical disconnection of the fallopian tubes

Considered permanent Reversal is costly, difficult, and not guaranteed

Benefits Most effective method for women Can be done at same time of c-section

Risks Surgical risk Ectopic pregnancy more likely No STI protection

+Vasectomy

Surgical disconnection of the vas deferens Prevents sperm from entering the

ejaculate

Benefits Most effective male method

Risks Surgical risks Possible sperm in ejaculate for up to 3

months No STI protection

+Male Condom

97% effective When used properly and

consistently

Benefits Cheap Easy to use Some STI protection

Disadvantages Latex allergies Breakage/slip off Poor use technique