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