contraceptives contraceptives againstconception most people - two needs: protection from pregnancy...

CONTRACEPTIVESCONTRACEPTIVES


againstagainst conceptionconception

Most people - two needs:Most people - two needs: protection from pregnancyprotection from pregnancy protection from STDsprotection from STDs


Contraceptives can fail due to:Contraceptives can fail due to: method failure (varying %)method failure (varying %) user failureuser failure

Why?Why? embarrassmentembarrassment inhibitionsinhibitions not spontaneousnot spontaneous memory failurememory failure moodmood awkwardnessawkwardness dulled sensationdulled sensation alcohol, other drugsalcohol, other drugs


Why? (Cont’d)Why? (Cont’d) fear parents will find outfear parents will find out fear to go to the doctorfear to go to the doctor heat of the momentheat of the moment ashamed to buyashamed to buy expenseexpense takes the danger out of lovetakes the danger out of love embarrassed to ask male partnersembarrassed to ask male partners lots of guys hate condomslots of guys hate condoms


Before Judeo-Christian era, women used Before Judeo-Christian era, women used different mixtures quite effectively.different mixtures quite effectively. Ex: camel or crocodile dung, herbal preparationsEx: camel or crocodile dung, herbal preparations

Knowledge gradually disappeared due to Knowledge gradually disappeared due to religious restrictions. (Patriarchal societies)religious restrictions. (Patriarchal societies)

Most common contraceptive around the world:Most common contraceptive around the world: breastfeeding!breastfeeding!

Second most common: Second most common: tubal ligationtubal ligation

Myths about contraceptionMyths about contraception


Research and education hampered by Research and education hampered by religious opposition in many countries:religious opposition in many countries: influence on lawinfluence on law jail for contraception providers – Margaret jail for contraception providers – Margaret

SangerSanger Still an issue in some countries, including Still an issue in some countries, including

some states in the USAsome states in the USA In Canada: Pierre Trudeau: the state has no In Canada: Pierre Trudeau: the state has no

business in the bedrooms of the nation – led business in the bedrooms of the nation – led to liberalized laws regarding sexual behaviour to liberalized laws regarding sexual behaviour (1969)(1969)

CONTRACEPTIVESCONTRACEPTIVES BARRIER METHODS:BARRIER METHODS:

Male condom:Male condom:• latex (best) or intestinal tissue of latex (best) or intestinal tissue of

animals (mostly lambs), lubricated or animals (mostly lambs), lubricated or unun

• better: polyurethane, thinner, better: polyurethane, thinner, stronger, conduct heat but a bit looserstronger, conduct heat but a bit looser

• relatively cheap – depends on relatively cheap – depends on frequency of use!frequency of use!

• protects against STDs (latex only)protects against STDs (latex only)• no prescription or fittingsno prescription or fittings• easily available (in urban areas) now easily available (in urban areas) now

internetinternet


BARRIER METHODS (Cont’d):BARRIER METHODS (Cont’d): Male condom (Cont’d):Male condom (Cont’d):

• failure rate 10-12% due to user mistakesfailure rate 10-12% due to user mistakes• many men dislike it, reduced sensation (?)many men dislike it, reduced sensation (?)• spontaneityspontaneity• damaged by heat (pocket), fingernailsdamaged by heat (pocket), fingernails• need to be used with other contraceptive methods need to be used with other contraceptive methods

to prevent STDsto prevent STDs

CONTRACEPTIVESCONTRACEPTIVES BARRIER METHODS (Cont’d):BARRIER METHODS (Cont’d):

Female condom:Female condom:• polyurethane, lubricated, two polyurethane, lubricated, two

rings, one over cervix, one rings, one over cervix, one over vulvaover vulva

• polyurethane more resistant polyurethane more resistant to tears and other damageto tears and other damage

• female controlfemale control• expensiveexpensive• high failure rate (preliminary)high failure rate (preliminary)• spontaneityspontaneity• awkwardawkward


Diaphragm: no longer available in NLDiaphragm: no longer available in NL• rubber with ringrubber with ring• covers cervix loosely but stays in place if covers cervix loosely but stays in place if

properly fittedproperly fitted• used with contraceptive cream/jellyused with contraceptive cream/jelly• failure rate in US 18%, due to misuse, lower failure rate in US 18%, due to misuse, lower

in Europe and Latin Americain Europe and Latin America• can be inserted 6 hrs. before, must be left in can be inserted 6 hrs. before, must be left in

6 hrs. after6 hrs. after• can be left in place for repeated sexcan be left in place for repeated sex• need Dr.’s fitting and prescriptionneed Dr.’s fitting and prescription• does not protect against STDsdoes not protect against STDs


BARRIER METHODS (Cont’d):BARRIER METHODS (Cont’d): Diaphragm (Cont’d):Diaphragm (Cont’d):

• must be with owner when neededmust be with owner when needed• failure due to arousal changes in vagina failure due to arousal changes in vagina

(ballooning), large changes in weight, birth, etc. (ballooning), large changes in weight, birth, etc. need resizingneed resizing

• cream or jelly can be irritating to women or partnercream or jelly can be irritating to women or partner• not advisable during menstruationnot advisable during menstruation• needs to be washed and dried thoroughly after needs to be washed and dried thoroughly after

each useeach use• no harmful side effectsno harmful side effects• inexpensive inexpensive


Cervical Cap: Cervical Cap: not available in NLnot available in NL

• similar but more difficult to insertsimilar but more difficult to insert• fits more snugly over cervixfits more snugly over cervix• doctors in North America not doctors in North America not

trained to fit it or instruct patienttrained to fit it or instruct patient• can be left in longer but risk of TSS can be left in longer but risk of TSS

and infectionsand infections• high failure rate in the UShigh failure rate in the US• no STD protectionno STD protection


Lea’s Shield Lea’s Shield (now there are different brand names)(now there are different brand names)

• is a one-size-fits-all reusable vaginal barrier is a one-size-fits-all reusable vaginal barrier contraceptive device. Approximately the size of a contraceptive device. Approximately the size of a diaphragm, it is composed entirely of medical diaphragm, it is composed entirely of medical grade silicone rubber. The device is washable and grade silicone rubber. The device is washable and reusable.reusable.

• does not compare with any other mechanical does not compare with any other mechanical device on the level of form, volume or matter. device on the level of form, volume or matter. Unlike other barrier contraceptives, it does not Unlike other barrier contraceptives, it does not depend on vaginal dimensions or cervical size depend on vaginal dimensions or cervical size which vary from woman to woman.which vary from woman to woman.


INTRAUTERINE DEVICESINTRAUTERINE DEVICES Different shapes, materials.Different shapes, materials. Inserted inside uterine cavity by physician.Inserted inside uterine cavity by physician. Can work by preventing sperm from Can work by preventing sperm from

swimming up or by preventing implantation. swimming up or by preventing implantation. Unknown.Unknown.

Very old method.Very old method. Some brands caused PID (pelvic Some brands caused PID (pelvic

inflammatory disease) leading to permanent inflammatory disease) leading to permanent infertility, ectopic pregnancies and infertility, ectopic pregnancies and hemorrhaging. hemorrhaging.


INTRAUTERINE DEVICES (Cont’d):INTRAUTERINE DEVICES (Cont’d): Can perforate uterine wall. Can perforate uterine wall. If woman becomes pregnant, high risk of If woman becomes pregnant, high risk of

miscarriage.miscarriage. Periods heavier, cramping, bleeding between Periods heavier, cramping, bleeding between

periods.periods. No protection against STDs.No protection against STDs. Can be expelled by uterine contractions.Can be expelled by uterine contractions. Some women very happy with this method.Some women very happy with this method.

CONTRACEPTIVESCONTRACEPTIVES CHEMICAL CONTRACEPTIVES:CHEMICAL CONTRACEPTIVES:

Spermicides:Spermicides:• Chemical substances that kill sperm. Chemical substances that kill sperm.

Ex: nonoxynol-9. Cream, jelly or foam.Ex: nonoxynol-9. Cream, jelly or foam.

• Irritation or allergic reaction.Irritation or allergic reaction.• Also added to other contraceptives.Also added to other contraceptives.• By itself high failure rateBy itself high failure rate

Sponge:Sponge:• Combination barrier and spermicide. 25% failure Combination barrier and spermicide. 25% failure

rate.rate.• No prescription needed, intercourse can be No prescription needed, intercourse can be

immediate or within 24 hrs.immediate or within 24 hrs.• Increases rate of TSS and UTIs.Increases rate of TSS and UTIs.• Currently off market.Currently off market.

CONTRACEPTIVESCONTRACEPTIVES HORMONAL CONTRACEPTIVES:HORMONAL CONTRACEPTIVES: Pill:Pill:

• Estrogen and progestin (synthetic progesterone)Estrogen and progestin (synthetic progesterone)• After period estrogen low, prompts FSH. Pill blocks After period estrogen low, prompts FSH. Pill blocks

this by elevating estrogen. 95% effective. (ideal this by elevating estrogen. 95% effective. (ideal users)users)

• Progestin helps byProgestin helps by inhibiting production of LHinhibiting production of LH thickening cervical mucus (sperm get stuck)thickening cervical mucus (sperm get stuck) changing the endometrium so implantation is unlikelychanging the endometrium so implantation is unlikely

• Different types of pill, see text.Different types of pill, see text.• ““Mini pill”: progestin only, less effectiveMini pill”: progestin only, less effective


HORMONAL CONTRACEPTIVES: HORMONAL CONTRACEPTIVES: Norplant: Norplant: currently not availablecurrently not available

• Subcutaneous implants of silicone cylindersSubcutaneous implants of silicone cylinders• Small surgical procedure (upper arm)Small surgical procedure (upper arm)• Contains progestinContains progestin• Inhibits ovulationInhibits ovulation• Thickens vaginal mucusThickens vaginal mucus• Prevents thickening of endometriumPrevents thickening of endometrium• Removal is difficult (scar tissue grows around it) Removal is difficult (scar tissue grows around it)

same pros and cons as pill except forgetting, so same pros and cons as pill except forgetting, so highest effectiveness.highest effectiveness.


HORMONAL CONTRACEPTIVES (Cont’d):HORMONAL CONTRACEPTIVES (Cont’d): Depo-Provera:Depo-Provera:

• Injectable progesterone (medroxyprogesterone) prevents Injectable progesterone (medroxyprogesterone) prevents ovulation and changes mucus ovulation and changes mucus

• Breast cancer riskBreast cancer risk• OsteoporosisOsteoporosis• Irregular menstruationIrregular menstruation• AmenorrheaAmenorrhea• Weight gainWeight gain• HeadachesHeadaches• AnxietyAnxiety• Stomach pain, crampsStomach pain, cramps• DizzinessDizziness• Weakness, fatigueWeakness, fatigue• Loss of libidoLoss of libido


HORMONAL CONTRACEPTIVES HORMONAL CONTRACEPTIVES (Cont’d):(Cont’d): Quarterly shots of estrogen and progestinQuarterly shots of estrogen and progestin

Lunelle, Cyclo-provera, CyclofemLunelle, Cyclo-provera, Cyclofem 100% effective100% effective Same pros and consSame pros and cons Yasmin: ethinylestradiol + drospirenone (type Yasmin: ethinylestradiol + drospirenone (type

of progesterone) synthetic – recalled – unsafeof progesterone) synthetic – recalled – unsafe Patch: on fleshy body partsPatch: on fleshy body parts


SeasonaleSeasonale taken continuously for 3 monthstaken continuously for 3 months low dose estrogen and progestinlow dose estrogen and progestin only 4 menstrual periods per yearonly 4 menstrual periods per year what long-term consequences???what long-term consequences???

Plan BPlan B emergency contraceptionemergency contraception two progestin pillstwo progestin pills within 24 hours of unprotected sex: within 24 hours of unprotected sex:

• 95% effective95% effective the longer the interval, the lower the effectivenessthe longer the interval, the lower the effectiveness Plan B is now available prescription-free in most Plan B is now available prescription-free in most

provincesprovinces alternative: two or more pills of any contraceptive pillalternative: two or more pills of any contraceptive pill

CONTRACEPTIVESCONTRACEPTIVES Drugs that interact with oral contraceptives Drugs that interact with oral contraceptives

(partial list):(partial list): acetaminophen: pill lessens pain reliefacetaminophen: pill lessens pain relief alcohol: pill enhances alcohol effectsalcohol: pill enhances alcohol effects anticoagulants: pill decreases their effectanticoagulants: pill decreases their effect antidepressants: pill enhances their effectantidepressants: pill enhances their effect barbiturates: interfere with pill effectivenessbarbiturates: interfere with pill effectiveness penicillin: decrease pill effectivenesspenicillin: decrease pill effectiveness tetracycline: dittotetracycline: ditto

More & more people on prescription drugs: More & more people on prescription drugs: potential for dangerous interactionspotential for dangerous interactions

CONTRACEPTIVESCONTRACEPTIVES Side effects of hormonal contraceptives:Side effects of hormonal contraceptives:

blood clots, can lead to heart attack and blood clots, can lead to heart attack and strokestroke

can lodge in lungs (respiratory difficulties)can lodge in lungs (respiratory difficulties) carcinogens: carcinogens:

• mixed datamixed data• need more long term studies need more long term studies • increased breast cancer, ovarian & endometrial increased breast cancer, ovarian & endometrial • decreased cervical cancerdecreased cervical cancer• different studies yield different datadifferent studies yield different data

increased infertility after long term (over 10 increased infertility after long term (over 10 years) but could be due to ageyears) but could be due to age

CONTRACEPTIVESCONTRACEPTIVES Side effects of hormonal contraceptives:Side effects of hormonal contraceptives:

liver tumors, can lead to deathliver tumors, can lead to death Difficulty:Difficulty:

• so many different formulations, ever changingso many different formulations, ever changing• controversial, contradictory resultscontroversial, contradictory results• who funded the research? who funded the research?

of most done by pharmaceutical companies (biased)of most done by pharmaceutical companies (biased)

• how is the data obtained? how is the data obtained? many based on self-report. Long term vs. short termmany based on self-report. Long term vs. short term

increased monilia and trichomona vaginal infectionsincreased monilia and trichomona vaginal infections more susceptible to STDs (vaginal pH altered)more susceptible to STDs (vaginal pH altered) nauseanausea migraines or severe headachesmigraines or severe headaches drug interactions: either increase or decrease drug interactions: either increase or decrease

effectivenesseffectiveness


Side effects of hormonal contraceptives (Cont’d):Side effects of hormonal contraceptives (Cont’d): depressiondepression lower interest in sexlower interest in sex bloating and/or weight gainbloating and/or weight gain interfere with milk productioninterfere with milk production costcost forgettingforgetting infrequent sexinfrequent sex smokerssmokers break-through bleedingbreak-through bleeding no STD protectionno STD protection

Environmental effects: the urine of users of hormonal Environmental effects: the urine of users of hormonal contraceptives gets into the water systems affecting contraceptives gets into the water systems affecting animals and possibly humans.animals and possibly humans.

InitialInitial SymptomsSymptoms Possible ProblemPossible Problem

AA Abdominal pain (severe)Abdominal pain (severe) Gallbladder disease, liver Gallbladder disease, liver tumour, or blood clottumour, or blood clot

CC Chest pain (severe) or Chest pain (severe) or shortness of breathshortness of breath

Blood clot in lungs or Blood clot in lungs or heart attackheart attack

HH Headaches (severe)Headaches (severe) Stroke, high blood Stroke, high blood pressure, or migraine pressure, or migraine headacheheadache

EE Eye problems: blurred Eye problems: blurred vision, flashing lights, or vision, flashing lights, or blindnessblindness

Stroke, high blood Stroke, high blood pressure, or temporary pressure, or temporary vascular problems at vascular problems at many possible sitesmany possible sites

SS Severe leg pain (calf or Severe leg pain (calf or thigh)thigh)

Blood clots in legsBlood clots in legs

Remember “ACHES” for the Pill: Symptoms of Possible Serious Problems With the Birth Control Pill

CONTRACEPTIVESCONTRACEPTIVES NEW DEVELOPMENTSNEW DEVELOPMENTS

The vaginal ring (which may also have estrogen) The vaginal ring (which may also have estrogen) is a flexible polymer ring, inserted into the vagina is a flexible polymer ring, inserted into the vagina for three weeks at a time. Removal at the start of for three weeks at a time. Removal at the start of fourth week brings on periodfourth week brings on period

Skin patch: Skin patch: • emits estrogen and progestinemits estrogen and progestin• same as pillsame as pill• applied anywhere, once a weekapplied anywhere, once a week• four week cycle (three on, one off)four week cycle (three on, one off)• Not effective in heavy women (thick fat pad under skin Not effective in heavy women (thick fat pad under skin

prevents good absorption)prevents good absorption) Methotrexate (kills embryo) + misoprostol (a Methotrexate (kills embryo) + misoprostol (a

prostaglandin) causes uterine contractions. In prostaglandin) causes uterine contractions. In Dr.’s office. It’s an abortifacient.Dr.’s office. It’s an abortifacient.


NEW DEVELOPMENTS (Cont’d):NEW DEVELOPMENTS (Cont’d): Essure coil: Essure coil:

• inserted into Fallopian tubes through inserted into Fallopian tubes through the vagina and uterusthe vagina and uterus

• tissue grows around coil in 3 months, tissue grows around coil in 3 months, results in total blockageresults in total blockage

• sterility ($1,000, not covered)sterility ($1,000, not covered)

• not 100% effectivenot 100% effective

CONTRACEPTIVESCONTRACEPTIVES NEW DEVELOPMENTS:NEW DEVELOPMENTS: Male ContraceptivesMale Contraceptives

Testosterone enanthate:Testosterone enanthate:• inhibits sperm production (injection)inhibits sperm production (injection)

Vaccines, FSH stops sperm productionVaccines, FSH stops sperm production Male reversible contraceptiveMale reversible contraceptive

• IntraVas deviceIntraVas device• two flexible silicon plugs inserted into vas deferenstwo flexible silicon plugs inserted into vas deferens• new method being tested in India: a polymer new method being tested in India: a polymer

injected into the vas, disables sperminjected into the vas, disables sperm


Natural Methods: How good are they?Natural Methods: How good are they? breastfeeding: only under certain conditionsbreastfeeding: only under certain conditions rhythm or calendar: “Vatican roulette”rhythm or calendar: “Vatican roulette” withdrawal (coitus interruptus)withdrawal (coitus interruptus) avoid ejaculation (coitus reservatus)avoid ejaculation (coitus reservatus) sympto-thermal method: basal body sympto-thermal method: basal body

temperature + vaginal mucustemperature + vaginal mucus abstinenceabstinence

SYMPTOTHERMAL METHOD

+ovulatory mucus observation


PERMANENT (MORE OR LESS) SURGICAL PERMANENT (MORE OR LESS) SURGICAL METHODS:METHODS: Tubal ligation:Tubal ligation:

• Fallopian tubes cut, several methods, some failures. Fallopian tubes cut, several methods, some failures. • Usual surgical risks. Usual surgical risks. • Some evidence of increased incidence of hysterectomy for Some evidence of increased incidence of hysterectomy for

various problems.various problems. Vasectomy:Vasectomy:

• Much simpler surgery: vas deferens cut or blocked. Much simpler surgery: vas deferens cut or blocked. • Can be done for reversibility (50-70% success).Can be done for reversibility (50-70% success).• Two months wait for sperm already there to die.Two months wait for sperm already there to die.• Very small % of men experience post-surgery discomfort for Very small % of men experience post-surgery discomfort for

a few months, most OK in 48 hrs.a few months, most OK in 48 hrs.

Both methods still require condoms for STDs.Both methods still require condoms for STDs.

ABORTION:ABORTION: Widely used for centuries. Widely used for centuries. Even early Christianity did not condemn it.Even early Christianity did not condemn it. Until 20Until 20thth century: century:

• quickeningquickening Canadian laws not like U.S.Canadian laws not like U.S.

ABORTION (Cont’d):ABORTION (Cont’d): First trimester:First trimester:

• Very early (2-3 weeks):Very early (2-3 weeks): RU-486 – methotrexate + misoprostolRU-486 – methotrexate + misoprostol D & C (dilatation and curettage)D & C (dilatation and curettage) D & E (dilatation and extraction)D & E (dilatation and extraction)

ABORTION (Cont’d):ABORTION (Cont’d): Second trimester: (10%)Second trimester: (10%)

• Saline injection:Saline injection: Fetal death, delivery follows within 24 hrs.Fetal death, delivery follows within 24 hrs.

• Prostaglandin injection:Prostaglandin injection: Causes labourCauses labour

• D & E:D & E: Under general anesthetic.Under general anesthetic. Fetal skull may need to be crushed for passageFetal skull may need to be crushed for passage

• Hysterotomy:Hysterotomy: Like a Cesarean sectionLike a Cesarean section

• Hysterectomy:Hysterectomy: Removal of uterus and contentsRemoval of uterus and contents

contraceptives contraceptives againstconception most people - two needs: protection from pregnancy...

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