Contraception
David Blair Toub, M.D.
Dept. of Obstetrics and Gynecology
Pennsylvania Hospital
Methods
Oral Contraceptive Pills (OCP’s)
 Depo-Provera, Norplant
 Intrauterine Device (IUD)
 Male / Female Condom
 Diaphragm
 Emergency Contraception (EC)

Efficacy (modified from trussell, et. al 1990)
Failure Rate (Percent) During First Year of Use
6
6
5
4
3
3
2
2
0.8
0.5
1
0.3
0.1
0
Spermicides
Comb.
OCP's
Prog. OCP's Diaphragm
Condom
DepoProvera
0.04
Cu-T380A
Norplant
0.2
TL
Hormonal Contraception:
Combination OCP’s
Contain Synthetic Estrogen/Progestin
 Modern E2 Dosage ≤ 50 Mcg
 Despite Diversity, Side Effects and
Efficacies Similar
 Requires Patient Compliance
 May Be Monophasic or Triphasic

Combination OCP’s:
Mechanism of Action
Suppresses LH / FSH Release
(E2
FSH, P
LH)
 Progestin Thickens Cervical Mucus and
Alters Endometrium
 Major Effect Is Anovulation and
Impairment of Sperm Transport and
Oöcyte Implantation

Combination OCP’s:
Additional Benefits
Menstrual Regulation
 Decreased Risk of Anemia
 Ovarian, Endometrial CA:
Risk
 Lower PID Risk
 Prevention of Benign Breast Disease

Combination OCP’s:
Side Effects
Breakthrough Bleeding (≤ 25%)
 Amenorrhea
 Breast Tenderness, Nausea
 H/A (+/–)
 ?HTN
 ?Weight Gain

Combination OCP’s:
Risks
Thromboembolism (≥ 35 yo, Smoker)
 MI (Smokers Only):

– < 15 cig/day: 3X Risk
– > 15 cig/day : 21X Risk

Liver Adenomas (Very Rare)
Depo-Provera:
Inhibits Ovulation
 150 mg q3months (14 day grace period)
 Delayed Ovulation After Discontinuation
 Main Side-Effects:

– Amenorrhea
– AUB
– Weight Gain
– Hair Loss
Norplant:
Implantable for ≤ 5 Years
 Similar Side Effects as Depo-Provera
 Avg. Yearly Failure Rate: 0.8/100
(Increases : > 2/100 after 5 years)
 Occasionally Difficult to Remove

Barrier Methods:
Diaphragm: High Failure Rates
– Must Remain in ~6 Hrs post-coitus
– Best if Combined with Spermicide
– UTI Potential
 Condom: STD Protection, Inconsistent
Use by Men
 Female Condom: Cumbersome,
Learning Curve
 Today Sponge: As seen on Seinfeld

IUD: Overview
ParaGard (CuT380A), Progestasert
 Very Effective (~ TL), Reversable
 Risks OVERBLOWN
 Monogamy Essential, However
 Does Not Protect Against STD’s
 Can Remain for ≤ 10 Years

IUD:
Mechanisms of Action
NOT ABORTIFACIENT!!!!!!!!
 Prevents Conception:
– Sperm Transport Inhibited
– Sperm Survival / Capacitation
Diminished
 Prevents Implantation: hCG Levels = 0

IUD:
Work-up
History: STD’s, Sexual History, Ectopic
 PEx: Size / Configuration of Uterus
 Cervical Cultures, Pap
 Counseling

IUD:
Contraindications
Lack of Monogomy, High Risk for STD’s
 Abnormal Uterine Bleeding
 Current Pelvic Infection (GC, Chl)
 Actinomyces on Pap
 ???Nulliparity
 Pregnancy
 Wilson’s Dz, Cu Allergy (both rare)

IUD:
Complications
PID: Usually 20 Insertional Contamination
– Unproven Role for Prophylactic ABx
 Hypermenorrhea
 Expulsion
 Perforation (< 0.1%)
 Failure: IUD Should be Removed
 ??Ectopic

Emergency Contraception
IUD, OCP’s
 Specific OCP Regimens Given ≤ 72
Hours After Unprotected Intercourse
~ 75% Effective
 Yuzpe Method: Ovral 2 tabs po now and
2 tabs 120 later
 May Cause Nausea
 Consider Dispensing at Yearly Visit

Special Circumstances
Postpartum/Postabortion:
– IUD, Progestins, Combination OCP’s*
 Anticonvulsant/Antibiotic Use:
– TCN Probably OK
– Most Anticonvulsants Impair Efficacy
of Hormonal Contraceptives

* may affect lactation before milk flow established
Summary
A Limited, but Diverse Range of
Contraceptive Options Exist in the USA
 Barrier Methods Tend to Have Higher
Failure Rates than Hormonal Methods
and the IUD
 The IUD is Underutilized
 All Methods have Risks and May Not be
Appropriate for all Patients
