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: TypesDepo-Provera (Injection every 12-14 weeks) Advantages

Reversible Good safety profile Effective - 0.3% failure rate

Disadvantages 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: TypesDepo-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

Nausea and vomiting Breast tenderness Headache Dizziness

Examples 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

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

ObjectivesThe 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 - TypesTubal ligation and/or resection Advantages

Immediately effective Very effective and permanent Can be done on ambulatory basis

Disadvantages Anesthesia risks Potential for perforation of organs Potential for emergency hospitalization Potential for bleeding Potential for infection

Female Sterilization - TypesTubal 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 silasticrings 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

Local anesthetic Office procedure

Disadvantages 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 presentationOb-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 presentationPast 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 presentationPhysical 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 presentationLaboratory 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 > 30b. Immobilityc. Excessive varicositiesd. Family history of DVT in first-degree relative

under 45

Teaching Points

4. A non-hormonal IUD or sterilization are optimal choices of contraception in this patient.

5. 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.)