Chapter 10
Contraception
Historical and Social Perspectives
• Evidence of contraception since the beginning of
recorded history
• U.S. contraceptive efforts
– 1800s Comstock laws:
– 1915: Margaret Sanger
• Opened illegal clinic.
• The Woman Rebel.
– U.S. Supreme Court rulings
• Griswold vs. Connecticut (1965)- Married couples.
• Eisenstadt vs. Baird (1972) - Unmarried individuals.
– Today:Far-Right politics, denying contraceptive to 3rd world. Pro-Life anticontraception politics.
Contraception as a contemporary issue
- in the U.S. • Allows couples to plan for wanted children, establish
relationship, financial stability
• Allows women to pursue professional life with more
freedom
• Can increase women’s health
– Pregnancy itself has health risks, spacing pregnancies at
least 18 months apart results in better health for both
mothers and children
• Increased pressure to mandate health insurance
coverage for prescription contraceptives
– Many health insurance companies covered Viagra before
they covered the pill
– Coverage has increased, but is still not universal
Sex, politics, & contraception
• Many pro-life religious groups oppose contraception and
want to prevent access to it.
– Don’t see contraception as a way to prevent abortion, but as “a
gateway to abortion” (American Life League)
– Many pro-life groups embrace traditional role of women staying
home raising children as the ideal
– Has led to decreased funding for clinics that provide free or
affordable birth control, and a higher rate of abortion.
• View access to contraception as a threat b/c it helps women expand their
roles into traditionally male realms of work & politics
• Bush administration
– Political influence of these groups has increased
– Anti-contraception policies have been extended globally
• international anti-contraceptive organizations
• Bush admin’s refusal to release $34 million that Congress appropriated to
provide contraception and reproductive health services internationally
Contraception as a global issue
• Helps curtail global population growth & spread of HIV
– Most successful way
to reduce population
growth worldwide is
to expand women’s
educational and
economic
opportunities
– Worldwide, women
w/more education
have fewer children
• Different cultures and religions have different views about
contraception
– EX: Catholic church forbids contraception (other than abstinence
and cycle-based methods), though 70% of American Catholics
use contraceptive methods forbidden by the Church
A look at the state of Kerala in India
• Primarily rural, similar to rest
of India; income level also not
different from rest of India
• Why does Kerala have such a
low birth rate and infant
mortality rate?
• High rate of women’s literacy
(85% in Kerala, compared
w/<40% in India on avg)
• Higher status for women in
Kerala- women can own land;
rather than having to pay a dowry to
marry a woman off, women in Kerala
bring their families a brideprice & are
considered an asset to the family
Sharing responsibility in choosing a
birth control method
• Sharing responsibility is in the interest of both partners
– Can enhance relationship trust
– Can be a good way to practice
discussing personal & sexual topics
– Women respect men who share
responsibility and often resent
men who do not.
– Men shouldn’t assume that a
woman is “taking care of it”
– Dealing w/an unplanned
pregnancy is difficult
• How to share responsibility
–
–
–
–
ask about BC before intercourse
read & discuss options together
attend a class or clinic together
share expenses
Choosing a Birth Control Method
things to consider
• Effectiveness--statistics show two numbers:
– Failure rate: # of women per 100 who become pregnant
after 1 yr. when using a b.c. consistently & correctly
– Typical use failure rate--takes into account improper or
inconsistent use
• Factors that contribute to improper use include: lack of partner
involvement, forgetfulness, feeling guilty about sex, poor
communication w/partner, not wanting to appear “easy”
– About half of all unintended pregnancies occur among
women using contraceptives
• Cost
• Ease of use
• Side effects
Effectiveness of birth control methods
Also see
Table
10.1
p. 268
w/o spermicide
FDA, 1997
Using backup methods to increase
contraceptive effectiveness
• Backup methods: contraceptive methods used
simultaneously w/another method to support it
• Condoms, foam, diaphragm, can all be combined w/other
methods for extra protection
• When a backup method might be a good idea:
– If on the pill:
• During first cycle of the pill
• After forgetting 2 or more pills, or after several days of diarrhea or
vomiting when on the pill
• First month after switching pill type
• When taking medications that can reduce effectiveness of the pill
– During first 1-3 months after IUD insertion
– When first learning how to use a new method
– To increase overall effectiveness of contraception
“Outercourse”
…is to prevent
pregnancy, not to
protect against
STI’s
• Noncoital forms of sexual intimacy
• Kissing, touching, mutual masturbation, oral sex, anal
sex
• Any type of sexual intimacy that avoids male
ejaculation near vaginal opening
• Can be primary or temporary means of preventing
pregnancy
• Can also be used when it’s not advisable to have
intercourse for other reasons, such as after childbirth
or abortion
• No undesirable contraceptive side effects
• Does not eliminate chances of spreading STDs,
especially if it involves oral or anal sex
Hormone-based contraceptives
5 types
1) Oral contraceptives (pills)
2) Vaginal ring
3) Transdermal patch
4) Injected hormones
5) Hormonal IUDs
Gonadotropin releasing
hormone (GnRH) triggers
release of gonadotropins
FSH & LH
How hormonal
contraceptives
work
FSH & LH trigger
ovulation
 Estrogen & progesterone in
hormonal contraceptives
inhibit LH, FSH, and GnRH
secretion, preventing ovulation

Progesterone also:
•thickens cervical mucus to prevent
Passage of sperm into the uterus
•changes uterine lining to inhibit implantation
Types of oral contraceptives
• Constant-dose combination pill
– Contains both estrogen and progestin
– Dose of each is constant throughout cycle
– Amount of estrogen in pills has decreased from approx. 175
micrograms in 1960 to avg. of 25 micrograms today
• Triphasic pill
– Levels of hormones (estrogen & progestin) fluctuate during cycle
• Seasonale
– Reduces the # of menstrual periods to 4 instead of 13 per year
– Has lower dose of estrogen and progestin
• Progestin-only pill
– Low dose of progestin and no estrogen
– For women who should not take estrogen (breastfeeding, high
b.p., at risk for blood clots, smoke)
How to use oral contraceptives
• Different types of OCs will differ in how to begin,
and other instructions--read instructions carefully &
talk w/health care practitioner
• Don’t skip pills, regardless of whether or not you
are having sex
• Take pill at the same time each day
– If you miss 1 pill: take missed pill as soon as you
remember, and then take next pill at the regular time
– If you miss >1 pill: consult health care practitioner for
advice; use a backup method for remainder of your cycle
Oral contraceptives
possible side effects & health issues
• Women who should not take OCs:
– history of blood clots, strokes, heart/circulation
problems, jaundice, breast or uterine cancer, liver
disease
• Women considered risky for taking OCs:
– Women who smoke, have migraines, depression, high
b.p., epilepsy, diabetes/prediabetes, asthma, varicose
veins
• Side effects of OCs can include:
– Weight gain, decreased sexual interest, headaches,
mood changes, nausea, bleeding between periods
– May clear up after 2-3 cycles on the pill
Oral contraceptives
possible side effects & health issues
• Rare but serious side effects of OCs--must be
reported to a health care practioner ASAP
10.3
Other hormonal methods
(contain both estrogen and progestin)
• Vaginal ring (Nuvaring)
– 2” ring inserted into the vagina during period
– Worn for 3 weeks, removed for 1 week, then
replaced with new ring
– Cost per year: $580
– Pros: no daily pill; spontaneity
– Cons: no STD protection, not effective for
women over 198 lbs.
• Transdermal patch (Ortho Evra)
– Patch is placed on buttock, abdomen, outer
upper arm, or upper torso
– Replaced weekly for 3 weeks, then a patchfree week
– Cost per year: $420
– Pros: no daily pill; spontaneity
– Cons: no STD protection, skin irritation
Other hormonal methods
• Injected Contraceptives
–
–
–
–
–
Depo-Provera (prog.); Lunelle (prog.+est.)
Injections: D-P every 12 weeks; Lunelle monthly
Cost per year: $196 for D-P; $420 for Lunelle
Pros: no daily pill; spontaneity
Cons: no STD protection, weight gain,
bleeding, mood change, frequent clinic visits
– D-P: takes up to 10 months for a woman
to get pregnant after stopping injections
• Contraceptive Implants
–
–
–
–
–
–
1.5” rod is inserted under skin of upper arm
Progestin-only
Effective for up to 3 years
Cost not yet known
Pros: no daily pill; spontaneity
Cons: no STD protection, weight gain,
bleeding, mood change, surgical procedure
(cont.)
Barrier & spermicide methods
• Include:
– Condoms (male & female)
– Spermicides (foam, sponge)
– Cervical barriers (diaphragm & cervical cap)
• Work by preventing sperm from reaching an
egg
• Only condoms provide protection against
STIs
Condoms
(male)
• Sheath that fits over the erect penis
• The only temporary method of birth
control for men
• Only form of contraception that
effectively reduces STI transmission
• Made of thin latex, polyurethane, or natural membrane
– Natural membrane (from sheep intestines) condoms can permit passage
of viruses, incl. those that cause AIDS, herpes, hepatitis, HPV
• Many varieties
– Different features, shapes, textures, colors, flavors
– Some “extended pleasure” types have a desensitizing agent on the
inside to delay ejaculation
– Lubricated or nonlubricated
• Note: average shelf life of condoms is 5 years; don’t store latex
condoms in hot places (glove compartment, back pocket) b/c heat
can deteriorate the latex
How to use the
(male)
condom
• Pinch reservoir tip or twist tip of nonreservoir tip condom before
unrolling condom over the penis to leave room for ejaculate-reduces chance of condom breaking
• Unroll condom over erect penis before any contact between the
penis and vulva occurs
– Common error: putting on a condom after vaginal penetration but
before ejaculation--increases risk of pregnancy & STI transmission
• Use a water-based lubricant to reduce risk of condom breaking (oilbased lubricants deteriorate condom)
• Hold condom at the base of the penis before withdrawing from the
vagina to avoid spilling semen inside vagina
Female condom
• Consists of two flexible polyurethane rings and a
soft, loose-fitting polyurethane sheath
– One ring at closed end fits loosely against cervix; other
ring at open end encircles the labial area
• Can be inserted before sexual activity; don’t need to
remove it immediately following ejaculation
Costs, pros, & cons of condoms
• Costs
– Male condoms, about $0.75-$1 each
– Female condoms, about $3 each
• Advantages
– STI protection!
– Available w/o prescription or medical intervention
• Disadvantages
– Can reduce sensation
• Polyurethane transmits heat well, so some say that the female
condom has less reduction in sensation
– Interruption of sexual experience (though some couples find
sensual ways of incorporating condoms into foreplay)
– Note: female condom can be inserted several hours before intercourse
Vaginal spermicides
• Include: foam, sponge, suppositories,
creams, film
• Spermicide: chemical that kills sperm
(nonoxynol-9)
• Cost: $0.85 per application
• Advantage: no prescription necessary
• Disadvantages:
– Interruption of sexual experience (except
for the sponge)
– Skin irritation (which can increase
susceptibility to STI infection)
– No protection from STIs
– Not effective enough to be used w/o a
condom or other method
Cervical barrier devices
• Covering the cervix is one
of the oldest methods in
contraceptive history
– Casanova (18th century Europe)
promoted using squeezed-out
lemon half; European women
shaped beeswax to cover cervix
diaphragm
FemCap
Cerv cap
Lea’s shield
• Cervical cap: covers cervix only
• Diaphragm: covers upper
vaginal wall behind cervix underneath pubic bone
• FemCap & Lea’s shield have removal straps
• Lea’s Shield allows a one-way flow of fluid from cervix
to vagina
• Method is usually combined w/spermicide
How to use cervical barrier devices
• Diaphragm & cervical cap: need to be fitted (may need to be refitted
w/weight gain or loss >10 lbs.)
• FemCap & Lea’s Shield do not have to be fitted, but still require a
prescription in the U.S.
• Use diaphragm & cervical cap only with water-based lubricants b/c
they are latex (FemCap & L.S. are silicone)
• Can insert up to 6-8 hr. before intercourse; should leave in at least 8
hr after
Placement of cervical barrier devices
(& FemCap)
Intrauterine Devices (IUDs)
• Small plastic objects
into uterus
• 2 types
– Hormone-releasing
– Copper-releasing
inserted
(progesterone)
progesterone
• Have fine plastic
threads
attached that
hang slightly
out of cervix into vagina for removal
• Very high continuation rate (how many women are
still using it one year after starting) compared w/other
methods
IUD Mechanisms of Action
Levonorgestrel-Releasing
IUD
(LNG-IUS, Mirena®)
– Inhibits fertilization
– Thickens cervical mucous
– Inhibits sperm function
– Thins and suppresses the
endometrium
Copper-Releasing IUD
(ParaGard® T380A)
– Inhibits fertilization
– Releases copper ions (Cu2+)
that reduce sperm motility
– May disrupt the normal
division of oocytes and the
formation of fertilizable ova
Jonsson B, et al. Contraception. 1991;43:447-458; Videla-Rivero L, et al. Contraception.
1987;36:217-226; Kulier R, et al. Cochrane Database Syst Rev. 2006;3: CD005347.
Costs, pros, & cons of IUDs
• Costs
– Copper: $550 (good for up to 10 years)
– Hormone: $500-$700 (good for up to 5 years)
• Advantages
–
–
–
–
–
Very effective (essentially no “user error”)
Long-term protection
No interruption of sexual activity
Don’t have to remember to use
Can be used during breast-feeding
• Disadvantages
– No STI protection
– Risk of PID (usually within first 1-2 months following insertion)
– Rare incidence of perforating uterine wall
Emergency Contraception
• Works mainly by preventing ovulation or fertilization
• In theory, can also interfere w/implantation
– Evidence suggests this is not primary mechanism of action
• If it was, efficacy should not decrease w/short-term delay, as long
as EC was administered some time before implantation
• However, EC is increasingly less effective w/delay
• Oral contraceptive pills
–
–
–
–
95% effective within 24 hrs; 75% effective within 72 hrs
Preven: 2 doses of combined estrogen & progesterone
Plan B: 2 doses of progesterone
Other combinations of oral contraceptives can substitute for
these (see Table 10.7, p. 283)
• Copper-T IUD
– 99% effective if inserted within 5 days
Fertility Awareness Methods
• Standard days method
– For women w/cycles btwn 26 & 32 days
– Couples avoid unprotected intercourse btwn days 8-19 of each
menstrual cycle
– Highest rate of effectiveness of natural family planning methods
• Mucus method: based on cyclical changes
– Vaginal secretions change throughout cycle; woman learns to
“read” these changes and keeps a daily chart
• Calendar method: self- knowledge of fertility
– After charting cycles for some time (preferably 1 year), a woman
estimates the time she is ovulating based on the calendar
• Basal body-temperature
– Based on changes in body temperature around ovulation
• Often, some combination of these methods will be used
Standard Days Method (w/Cyclebeads)
1 On the day you start your
your period, move the
ring to the RED bead.
If you have not started
your period by the day
after you put the ring on
the last brown bread,
contact your provider.
If you start
your period
before you put
the ring on the
darker brown
bead, contact
your provider.
(may not be a good
method for you)
On BROWN bead
days
you can
have intercourse
with very low
probability of
pregnancy.
Also, mark this date
on your calendar
2 Every morning
move the ring
to the next
bead.
On WHITE bead days
you can get pregnant.
Always move
the ring from
the narrow to
the wide end.
Avoid unprotected
intercourse to prevent
a pregnancy.
Arevalo M et al., Contraception, 2002;65:333-338.
When you start your
next period, move the
ring directly to red
bead and begin again.
Cervical Mucus Method
no unprotected
intercourse
Early
Mucus
Transitional
Mucus
Highly Fertile
Mucus
• Slight amount
• Thick
• White
• Sticky
• Holds its shape
• Increasing
amounts
• Thinner
• Cloudy
• Slightly stretchy
• Profuse
• Thin
• Transparent
• Stretchy
Stanford JB, et al. Obstet Gynecol. 2003;101:1285-1293.
Calendar or Rhythm Method
8
Low-risk Days
Egg may still
be present
These days may be
unsafe if 28-day cycle
varies as much as 8-9
days between shortest
and longest cycles.
Intercourse on these days
may leave live sperm to
fertilize egg.
Ovulation
Billings JJ. Med J Aust. 1978;2:436.
Byer/Shainberg/Galliano. Dimensions of Human Sexuality,
5e. 1999, The McGraw-Hill Companies, Inc.
Basal Body Temperature Method
• BBT=body temp in resting state on waking
• Slight drop immediately before ovulation
• After ovulation, release of progesterone
causes slight increase in temperature
Fertility Awareness Methods
pros & cons
• Pros:
–
–
–
–
Essentially free
No medical side effects
Does not interrupt sexual activity
Woman gains awareness about her body and natural
cycles, which can increase comfort w/sexuality
– Acceptable to Catholic Church
• Cons:
– No STI protection
– Requires some degree of discipline in order to keep track
of calendar/charts, etc.
– Need to abstain from intercourse or use a backup
method during fertile days
Sterilization
• Essentially permanent, although vasectomies are
sometimes reversible
• Does not affect hormones, desire, sexual functioning
• Female sterilization
– Tubal sterilization: fallopian tubes are severed to block
passage of sperm & eggs
– Transcervical sterilization: tiny coil inserted through cervix
into fallopian tubes
• Coil promotes tissue growth that, after 3 months, blocks fallopian
tubes
• Male sterilization (vasectomy)
– Safer, less expensive, fewer complications than female
sterilization
– Cutting and closing vas deferens (ducts that carry sperm)
Ex. of female sterilization procedure
• Laparoscope: narrow, lighted viewing instrument that is
inserted into abdomen to locate the fallopian tubes
Ex. of male sterilization procedure
• Vas deferens on
each side is cut;
small section is
removed, and the
ends are tied off or
cauterized
Less than Effective Methods
• Nursing
– amenorrhea is common for a brief period after birth while
breastfeeding
– 80% of women ovulate before first period (and so do not
know that they are fertile)
• Withdrawal before ejaculation
–
–
–
–
difficult to judge when to withdraw
anxiety may lower pleasure for both partners
Cowper's gland fluid may carry sperm
any sperm on vulva may travel into vagina/uterus
• Douching
– sperm reach uterus in 1-2 minutes
– douching may speed sperm along
– irritates vaginal tissue
New Directions in Contraception
for men
• The “male pill”: Testosterone & progestin may
lower sperm count
• New forms of reversible vasectomy
– Injection of a blocking gel into vas deferens; gel
is dissolved to reverse the procedure
– Insertion of two plugs into each vas deferens-can be removed later
New Directions in Contraception
for women
• Most new developments are improvements
on existing contraception for females
– Variations on methods of delivery, formulation of
hormones
– New designs of IUDs, female condoms
– spermicides with microbicides (to kill microbes
that cause STIs)
Discussion question:
Should women convicted of child abuse be
mandated to use “doctor-certified”
contraception (e.g. injected/implanted
hormonal contraceptive, or IUD)?